Management of Thoracic Outlet Syndrome W. ANDREW DALE, M.D., MALCOLM R. LEWIS, M.D. This overall management program for thoracic outlet compression syndrome is based upon experience with 153 extremities in 149 patients and the results of others. The following conclusions are documented and discussed. 1) Diagnosis is based chiefly upon history; physical signs are inconstant and often absent. 2) Major vascular problems are unusual; angiography is not always necessary. 3) Electromyography is not always critical but does aid in diagnosis of carpal tunnel syndrome. 4) Non-operative treatment relieves most patients; operative decompression is indicated for a minority. 5) Transaxiliary first rib resection, with removal of cervical rib is the best operation. 6) Carpal tunnel decompression should be done concomitantly when needed. 7) Operation is relatively safe.
DURING the past 7 years an integrated concept of management of thoracic outlet compression syndrome has been developing which produces good to excellent results in most patients. Numerous articles and increasing numbers of operations attest to widespread interest in the problem which 20 years ago was barely known. There are still unanswered questions relating to pathogenesis, misunderstanding of the clinical syndrome and only partial agreement upon indications and techniques of management. This retrospective study of 153 extremities in 149 patients is discussed in the light of our experience and the background of the reports of others and is particularly directed toward the continuing development of a rational method of overall management. Our experience with 153 upper extremities in 149 patients (1966-74) is summarized in Tables 1-5. Specifically excluded are 15 patients who eventually proved to have carpal tunnel syndrome alone. Follow-up range D from a month to 8 years. Surgeons do not usually discuss cases which do not require operation but since most people with thoracic outlet syndrome fall into the non-surgical category they are included here. Presented at the Annual Meeting of the Southern Surgical Association, December 9-11, 1974, Boca Raton, Florida.
From the Department of Surgery, Vanderbilt University School of Medicine, St. Thomas Hospital and Baptist Hospital, Nashville, Tennessee
Present Clinical Management Patients suspected of thoracic outlet syndrome are initially examined with emphasis upon the history of pain, paresthesias, edema and motor dysfunction (Fig. 1). Known aggravating factors such as injury, rib anomalies, unusual positions as well as general health factors are noted. Examination is directed toward tenderness, masses and bruits in the neck along with pain or pulse cut-off by arm position change. Sensory and motor tests, peripheral pulses, and temperature examination are also done. If the diagnosis of thoracic outlet syndrome (TOS) seems likely, shoulder girdle strengthening exercises (Table 6) are explained and the patient is asked to follow this program regularly for three weeks. Tranquilizers or sedatives to interrupt the cycle of nervous and muscular tension are often prescribed along with warm tub baths to promote relaxation of the muscles of the neck and shoulder girdle. Occasional patients are made worse by exercises and are warned to discontinue should this occur. During this three week period electromyography is done, the cervical spine and chest are x-rayed for anomalies, and a stress electrocardiogram and cardiac consultation are obtained if there is a component of chest pain. At the next office visit the results of exercise and the studies are evaluated and the patient either continued on nonoperative therapy, referred for cardiac therapy, or scheduled for carpal ligament lysis. If symptoms are not relieved there is given a week trial of cervical halter traction as an out-patient in the Physical Therapy Department. This does not help thoracic outlet syndrome but usually benefits cervical disk pressure and is therefore of differential diagnostic benefit.
575
576 Non-operated
Operated
Total
29 68 4 22 21 30 15 5
14 42 1 9 24 14 5 1
43 110 5 31 45 44 20 6
Plain x-ray: cervical rib 1st rib anomaly Anteriogram: abnormal Phlebogram: abnormal
97
56
153
Electromyogram: shoulder abnormality elbow abnormality wrist abnormality no abnormality
< 20 21-30 31-40 41-50 51-60 >60
Total
Should severe symptoms continue, hospitalization is arranged. Two-position subclavian angiograms and in some cases phlebograms are obtained. Neurosurgical consultation is requested and myelography if indicated. If thoracic outlet syndrome continues as the diagnosis the patient is offered (but not urged) brachial plexus decompression by the appropriate procedure and is advised of the expected chance of relief along with that of failure. By this time it is believed that other causes of the symptoms have been ruled out and that nonoperative therapy has been unsuccessful; most patients now request operation. Operations are therefore reserved for patients who continue to have symptoms and do not respond to lesser measures over a period of time. Occasionally, the symptoms may be so acute that immediate operative decompression is warranted. This occurs when pain of a severe degree necessitates opiates, or if the vascular structures are severely involved or become thrombosed. Method The best method to decompress the neurovascular bundle is removal of the first rib along with cervical rib if that is present. At least 4 approaches to the first rib are possible but the transaxillary is easiest and produces less pain and fewer complications once the technique is mastered. The patient is placed in the lateral thoracotomy position and the table later rolled back about 30-40o. The arm is sterilely draped into the field to allow traction upon it (Fig. 2). TABLE 2. Clinical Syndrome in 153 Extremities
History pain paresthesia motor weakness edema Examination pain in AER pulse cut-off
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TABLE 3. Laboratory Findings
TABLE 1. 153 Extremities of 149 Patients
Male Female Age:
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Total
Non-operated
Operated
97 63 17 14
56 26 18 11
153 89 35 25
14 21
12 20
26 (17%) 41 (27%o)
(100%) (58%) (23%) (16%)
Non-operated
Operated
Total
5 0
11 1
16 (12%) (1%)
2 of 5 (40%)
13 of 29 (45%) 15 of 34 (44%)
0 of 5 (0%o)
6 of 8 (75%)
6 of 13 (46%)
1
4
5
1
0
1
3
5
8
8
15
23
(400o of 38 were abnormal)
A transverse incision is made just below the axillary hairline and dissection from pectoralis major to latissimus dorsi muscle is deepened to the rib cage and then upward into the axilla until the vessels are encountered as they pass over the superior edge of the first rib. The key to a safe and efficient operation is the exposure provided by elevation of the shoulder girdle by upward traction by an assistant. Several methods of traction have been tried, including attachment of the arm to a movable pole for elevation and similar attachment to an overhead orthopedic traction device. The best exposure is obtained by a vigorous assistant holding the wrist and forearm in a hammerlock10 and pulling upward by leaning back to lift the neurovascular bundle off the first rib. Assistants may be alternated at 10 minute intervals. Approximately 20 minutes of exposure is currently required for careful dissection and removal of the first rib.* The sensory nerve crossing the axillary operative field is recognized and divided since an area of anesthesia on the medial upper arm is preferable to postoperative neuritic pain. The anterior scalene muscle is isolated at its attachment to the superior border of the first rib and divided. The first rib is dissected extraperiosteally to avoid regeneration. The dissection is carried out not only by curved, sharp periosteal elevators and scissors but also by the operator's finger which is more sensitive than steel instruments and is used wherever possible. The long thoracic nerve lying on the lateral rib cage is avoided to prevent scapular "winging" if injured. The rib is resected posteriorly near the transverse process of the vertebra *We have personally participated in this retraction and recommend that every surgeon proposing to do this procedure should familiarize himself with the problem similarly.
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THORACIC OUTLET SYNDROME OFFICE INTERVIEW XRAY NECK XRAY CHEST
ELECTROMYOGRAM CARDIAC STUDIESEXERCISE: 3 WEEKS FIG. 1. Flow pattern for current management of patients with thoracic outlet syndrome.
CERVICAL TRACTION: I WEEK
RELIEF
HOSPIT,AL
I
2 POSITION ARTERIOGRAM PH LEBOGRAM NEUROSURGICAL CONSULT-t? MYELOGRAM
OPERATION
57% EXCELLENT 36% PARTIAL 7 % FAILURE -* FAILURE semi-upright chest film is made in the Recovery Room to be certain that a pneumothorax is not overlooked. Secondly, the patient is encouraged to begin full overhead arm motion on the day following surgery and the Physical Therapy Department is enlisted to aid this maneuver
and anteriorly at its junction with the rib cartilage (Fig. 3). During the rib resection a special brachial plexus shield is placed between the rib cutter and the brachial plexus to protect it. Considerable help has been available recently from a newly developed extra-long doubleaction, thin-beaked rib rongeur which is superior to others which were previously available.* Resection of the rib posteriorly is more important than at its anterior junction with the cartilage. The operator looks to see if the brachial plexus impinges upon the cut end of the rib, feels for rough spicules, and lowers the arm to the side while two fingers are placed in the resected rib bed to be certain that decompression is adequate. If the underlying pleura has been opened the resultant pneumothorax is easily managed by placing a small catheter and sucking on this as it is withdrawn after the wound is closed in layers. If the pleura has not been entered a small Penrose drain is left in place for 24 hours. This is not placed if the pleura has not been opened for fear of direct communication and resultant pneumothorax. The operation requires 40 to 90 minutes, being more difficult in heavily muscled patients. Blood loss is minimal and no transfusion has ever been needed. Two points are stressed in postoperative care. First, a
should it prove necessary. A cervical rib is often accessible through the axillary approach after removal of the first rib (Fig. 4). If there is difficulty or if the patient is large or obese a secondary supraclavicular incision may be used (one in this series).* Illustrative Case Reports Case 1. A 44-year-old woman had vague pain in her right arm near the elbow with weakness of grip with incoordination. There were no positive physical findings nor x-ray abnormalities. Electromyography showed delay in nerve conduction both at the elbox and wrist. Exercises did not relieve the symptoms. Transaxillary first rib resection was performed with concomitant carpal tunnel release. Twenty-one months after operation she had no pain but said that her right upper extremity was so weak that she was "hardly able to work." There was some demonstrable weakness in the grip on that side. Comment. Should this patient be classified as an excellent result or as improvement? There are a combination
*This rib rongeur is available from Codman and Shurtleff, Pacella Drive, Randolph, Mass 02268.
*The 1971 description of operative technique for cervical rib moved by Clarence J. Schein is excellent.37
re-
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PI
.s:
FIG. 3A. Postoperative appearance after first rib resection. Clips placed during concomitant sympathectomy.
FIG. 2. Position for transaxillary resection of first rib. Arm is and draped into the field. Inset: Excised rib.
prepared
of factors which may suggest to the patient that she has good reason to avoid work at a boring job. She was classified as "improved." Case 2. A 33-year-old woman had transaxillary resection of the first rib for relief of shoulder and arm pain of 6 months duration associated with paresthesias in the left shoulder and arm. The preoperative pulse cut-off during elevation was changed and she obtained relief. The TABLE 4. Results of 56 Operations in 54 Patients
Complete Relief
Improved
20 14 49 Transaxillary 1st rib resect. + clavicle resect. 2 + cervical rib resect. 3 1 + carpal lysis 4 2 (subtotal: 1st rib removal) (29 = 60%o) (17 = 35%) 4 Resection cervical rib +scal1 enectomy 3 3 Scalenectomy only 2 Total 32 (57%) 20 (36%)
Failure
were
preoperative arteriogram had shown narrowing. Electromyography was normal. Nine months later there was recurrence of pain in the left lateral neck. Electromyography was again negative. Cervical myelography was negative. A previously recognized cervical rib on the contralateral (asymptomatic) side was still present and raised a question as to whether there might be a fibrous band on the painful side although x-ray again did not show any cervical rib or other anomaly of the bony cage. Thirteen months following the original operation the left neck was explored through a supraclavicular approach to be certain that there was no soft tissue band compressing the brachial plexus. Nothing was found. The medial half of the clavicle was resected and an additional amount of anterior scalene muscle was removed. She again had relief of pain. Two years later she was rehospitalized for recurrence of pain in the left neck and shoulder. There were no positive findings and she was treated symptomatically. Comment. This illustrates inability of her internist, a neurosurgeon and ourselves to obtain complete relief despite two operative procedures. The patient is classed as improved. Her symptoms are inconsistent, but it is uncertain whether operation had any specific decompressive effect.
2
1 (3
6%)
=
1
4 (7%)
Results There was some relief of symptoms by one method or another in 97% of the extremities (Table 4). Among those having surgery, 93% obtained complete or partial relief while 7% were failures in that symptoms were unchanged. None were made worse. There were no deaths. Complications are listed in
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.W.:
I
FIG. 3B. Extra long double action rongeur has thin beak for removal of posterior end of rib.
Table 5. All were temporary except for one patient who had a permanent limitation of elevation of the shoulder following inability to mobilize the shoulder properly postoperatively. Discussion The twisting road which has led to our present understanding of thoracic outlet syndrome began over a hundred years ago when the first clinical diagnoses were recorded and an early attempt was made to remove the first rib by Coote' in 1861.12 Prominent surgeons successively became interested in the problem, and in 1905, John B. Murphy of Chicago resected a cervical rib which had produced a subclavian aneurysm.22 By 1916 Halsted was able to find records of 716 patients with cervical ribs; he conducted experiments to determine the cause of the occasional aneurysm of the overlying subclavian artery. 13 Telford and Stopford demonstrated how the brachial plexus and subclavian artery could be compressed by the first thoracic rib and reported 6 patients who were relieved of symptoms following its resection.38 Adson, in 1927, reviewed the subject extensively and introduced his clinical test.' The role of the scalene anticus muscle in neurovascular compression was developed further by Naffziger and Grant23 and by Ochsner, Gage and DeBakey in 193525 and succeeding years saw other compression syndromes described. Peet and associates, in 1956, suggested that all of these compression syndromes might be termed thoracic outlet syndrome;26 this term was later modified by Rob and Standeven to thoracic outlet compression syndrome, which includes all synTABLE 5. Complications Deaths: 0 Infections: 0 Temporary long thoracic nerve injury 2 Acute bursitis of shoulder Stiff shoulder Pneumothorax requiring aspiration in recovery room Wound hematoma
2 2 2 1
A.
~POST- 0_
C.L
FIG. 4. Cervical rib at arrow was removed along with first rib by transaxillary approach.
dromes of compression of the neurovascular structures of the upper extremities.29 The term "neurovascular compression syndromes of the shoulder girdle" used by Rosati and Lord34 is more correct terminology but is bulky and since "thoracic outlet syndrome" has now been generally accepted (even by these authors) it will be used here. The significant failure rate of scalenectomy alone led to efforts to achieve greater decompression. McCleery and associates, in 1951, added removal of the costocoracoid membrane and subclavian muscle2 while Rosati and Lord, in 1961, emphasized claviculectomy.3 Resections of the first rib had been reported earlier4 and in 1962, Clagett redirected attention to this when he reported his good results after resection of the first rib via the posterior approach.5 Ferguson, Buford and Roper confirmed this in 12 other patients" and Clagett later increased his reported series to 44 successful first rib resections.18 Resection of the first rib via the axillary approach was described in 1966 by Roos31 whose series has been enlarged to over 450.32 This route allows removal of the rib without cutting muscles and has been productive of good
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TABLE 6. Shoulder-Girdle Exercises for Thoracic-Outlet Syndrome* At the beginning, each exercise is done 10 times in succession twice a day. As the shoulders and neck gain strength, the number of times each exercise is done consecutively can be increased. The six exercises follow: 1. Stand erect with the arms at the sides, holding in each hand a 2-pound weight (sandbags, or bottles, jars or sacks filled with sand). (a) Shrug the shoulders forward and upward. (b) Relax. (c) Shrug the shoulders backward and upward. (d) Relax. (e) Shrug the shoulders upward. (f) Relax and repeat. 2. Stand erect with the arms out straight from the sides at shoulder level; hold a 2-pound weight in each hand (palms should be down). (a) Raise the arms sideways and up until the backs of the hands meet above the head (keep elbows straight. (b) Relax and repeat. Note: As strength improves and exercises 1 and 2 become easier, weights should be made heavier; increase to 5 and later to 10 pounds. 3. Stand facing a corner of the room with one hand on each wall, arms at shoulder level, palms forward, elbows bent and abdominal muscles contracted. (a) Slowly let the upper part of the trunk lean forward and press to the chest into the corner. Inhale as the body leans forward. (b) Return to the original position by pushing out with the hands. Exhale with this movement. 4. Stand erect with the arms at the sides. (a) Bending the neck to the left, attempt to touch the left ear to the left shoulder without shrugging the shoulder. (b) Bending the neck to the right, attempt to touch the right ear to the right shoulder without shrugging the shoulder. (c) Relax and repeat. 5. Lie face down with the hands clasped behind the back. (a) Raise the head and chest from the floor as high as possible while pulling the shoulders- backward and the chin in. Hold this position for a count of three. Inhale as the chest is raised. (b) Exhale and return to the original position. (c) Repeat. 6. Lie down on the back with arms at the sides, with a rolled towel or small pillow under the upper part of the back between the shoulder blades and no pillow under the head. (a) Inhale slowly and raise the arms upward and backward overhead. (b) Exhale and lower the arms to the sides. (c) Repeat 5 to 20 times.
*From Fairbain, Juergens, Spittell, Peripheral Vascular Diseases, W. B. Saunders, Philadelphia 1972, Page 473.
results with few complications. Excision of the first thoracic rib removes the floor of the compression compartment and allows the neurovascular bundle to drop downward away from the overlying and enclosing structures.
Pathogenesis. The narrow space composed of firm or rigid structures through which course the nerves and vessels from the neck to the axilla easily causes pressure. The addition of congenital anomalies of ribs and muscles compounds this, as does any unusual position which is persistent, such as hyperabduction at work or during sleep, an injury, degenerative changes, and muscle spasm. Harold C. Urschel's diagram (Fig. 5) appears to be a reasonable explanation of how pressure occurs.40 Lord and Rosati have enumerated 5 factors which may contribute to pressure, namely: 1) congenital anomalies, muscles anterior scalene middle scolene
fascia bone costocoracoid membrane cervical rib clavicle
subclavius
pectoralis minor
vascular symptoms (5-10%) vein artery edema ischemia collaterals coldness cyanosis necrosis
nerve symptoms (98%)
PAIN 100% paresthesias 58% weakness 23%
2) static size or shape of compressing structures, 3) dynamic changes with motion, 4) trauma, including fractures and "whiplash," and 5) the aging processes of arteriosclerosis and muscle atrophy.20 The actual reason why some people develop pressure symptoms while most do not is unclear. The common occurrence in middle age (78% were 21-50-years-old in our series) and in women (72%) has suggested that muscle atrophy combined with increasing weight accounts for many instances. However, this explanation collapses with examination since age and obesity should cause even further loss of muscle tone, yet the incidence of symptoms diminishes as age advances. Cervical rib is said to occur in 1% of the population and to be symptomatic in 10%o of instances. Twelve per cent of our patients had cervical ribs and another one had an anomaly of the first rib. This crowding of the space understandably causes compression. Thoracic outlet symptoms not infrequently begin after injury, automobile whiplash accidents being the most common form in the United States. Sanders, Monsour and Baer noted that 52% of their 58 patients featured this,35 while Roos and Owens reported it in 34% of 138 patients. 3 The actual incidence is difficult to obtain since close questioning often brings out some memory of a neck or shoulder injury, in these patients which may be overlooked. The following conclusions are based upon review of our patients as well as the reports of others and are offered with knowledge that full documentation of these ideas is not possible and that some may prove to be erroneous.
FIG. 5. Thoracic outlet syndrome. Causes of pressure plexus, modified from Urschel.39
upon
brachial
1. Diagnosis is more dependent upon history than examination. Some form of pain is invariable. It is often
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and the patient finds localization difficult. It is not pin-pointed to the shoulder or elbow and may lead the inexperienced clinician to conclude that it is not real. The pain is due to nerve pressure and not to ischemia as has been thought in the past. Anterior chest pain may also occur. This has been termed pseudo-angina by Urschel and associates who differentiated brachial plexus pressure as it cause in 44 patients. Another 13 patients had both thoracic outlet syndrome and angina due to coronary arterial disease. They used coronary arteriography and electromyography to differentiate.42 Paresthesias are common (58% here) and more often involves the ulnar distribution, but also may be general. Motor incoordination (23%) may be manifest by dropping objects, or weakness of grip. Edema (16%) in this group was chiefly by history of enlarged finers and hands and was not usually pitting and demonstrable. Lack of postive physical findings was noted. Only a minority (17%) had pain when the arm was elevated and externally rotated. The Adson test for pulse cut-off was similarly disappointing, frequently resulting in numerous false positives in asymptomatic patients. The subjective nature of pain along with the paucity of objective findings often leads to uncertainly in diagnosis. Restriction of definitive treatment to those with a sure diagnosis will fail to provide available relief of pain to some patients while acceptance for surgery on the basis of loose indications leads to confusions and unnecessary vague
treatment.
A large number of differential diagnoses may be listed but the problem essentially comes down to three questions (Table 7). First, is pain of organic origin? Second, are the symptoms typical of nerve pressure, that is, pain which is widespread and poorly localized, or is the pain in a joint or tendon with local manifestations? The final question is whether the nerve compression exists at the level of exit of the nerves from the cervical vertebra, at the thoracic outlet, at the elbow or at the wrist. All of these pressure points occur, may co-exist and tend to be confuses. In this series no instance of compression at the elbow has been recognized, but 7 of the 59 patients undergoing operation also had lysis of the transverse carpal ligament at the wrist and an additional TABLE 7. Differential Diagnosis 1. Pain (a) is it of organic origin? (b) is it due to nerve pressure? (c) is the pressure; at the vertebral column & thoracic outlet? Elbow? wrist? 2. Common lesions to be ruled out: (a) cervical root pressure by disk; arthritis (b) shoulder "bursitis" (c) occlusion of arteries of wrist or hand (d) carpal tunnel syndrome
581 15 patients who originally were thought to have thoracic outlet syndrome were operated upon for carpal tunnel syndrome as the proper diagnosis (outside of this series). Symptoms of hand ischemia (Raynaud's phenomenon, coldness, or ulceration) are not ordinarily ptoduced by thoracic outlet syndrome but by Raynaud's disease or Raynaud's phenomenon secondary to other problems. In the older literature it is commonly stated that Raynaud's phenomenon may accompany thoracic outlet syndrome but we have not observed such (although we see a good many patients with hand and finger ischemia due to other causes).9 Brachial angiography is the key examination for differential diagnosis in this situation. 2. Major vascular problems are unusual; angiography is not always necessary. Vascular signs have been thought common but our experience denies this since only one arterial and three venous problems attributable to thoracic outlet pressure have occurred in the 8 year time period of this series. The arterial problem8 consisted of axillary thrombosis and required a graft as well as distal decompression (Fig.
6). The three venous cases of phlegmasia cerulea dolens treated by intravenous heparin. Only one of the three required venous thrombectomy (Fig. 7). The small number of serious vascular complications is were
attested by Roos' incidence of 6%,32 Sanders of 12%35
and Urschel's one arterial and 14 venous problems among 400 patients (4%).41 Judy and Heymann in 1972 reported only 53 major vascular complications in the English literature15 beyond the 29 earlier ones of Schein, Haimovici and Young.37
The arterial problems which do occur are generally associated with cervical ribs or other bony anomalies at the thoracic outlet. As long ago as 1939 Eden found only a single such case without a bone abnormality among a total of 42.10 More recently Raphael, Moazzez and Offen reaffirmed this in connection with 7 cases28 and Bland and Connar reported 6 arterial problems associated with cervical rib or first rib abnormalities among their 40 patients operated upon for thoracic outlet syndrome.3 Our patient with an arterial problem had a cervical rib. It is therefore not likely that a vascular complication will occur in the absence of cervical rib or anomalous first rib. This implies that angiography should be done when such bony anomalies are present. The results of twoposition angiography in other patients is less rewarding. Among 34 arteriograms in this series positive findings were limited to 44% of these angiograms. The changes consisted of minor degrees of stenosis due to external compression, often accompanied by a small amount of post-stenotic dilatation (Figs. 7 and 8). No aneurysms nor thromboses were discovered except for the one noted above. This is a considerably smaller percentage than the 70o of 158 patients studied by Land.17 The results of routine angiography have therefore been disappointing
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diagnosis of carpal tunnel syndrome. The 1968 report of Urschel, Paulson and McNamara that pressure slowed nerve conduction with postoperative reversal in 17 patients suggested this might become a critical objective test.39 Krogness studied 5 patients before and after scalenectomy4and first rib resection1 and reported similar findings.16 The electromyogram has not yet been widely accepted; Roos for example has stated that it was unrewarding in his work-up of 1700 patients. Disagreement between its advocates in regard to the effects of
.position is also noted. In the latter part of this series there were 38 patients who had electromyograms; only 40o were abnormal. Positive findings at the shoulder level were infrequent and the chief value of electromyography in our hands is to furnish information regarding never pressure at the wrist, which agrees with Lord's viewpoint.19 We are unable to explain the difference between our experience and that of the advocates of electromyography. But whatever the cause, we cannot rely upon it as a practical objective test for thoracic outlet syndrome at present.
FIG.6. (Top) The axillary artery is sharply compressed at the arrow when the upper extremity is elevated and abducted and this resulted in the distal embolism. (Bottom) The axillary artery appears normal with aA arm in the dependent position. The vein graft was used to bypass the old embolism and secondary thrombosis of the brachial artery. First rib resection and claviculectomy were also done.
and this test did not particularly aid in differential diagnosis or treatment. We now believe it should be used chiefly for patients whose history or physical examination casts suspicion upon the artery or when a bone abnormality is present and that it is not useful for the majority of patients with thoracic outlet syndrome whose symptoms are due to nerve pressure. Eight of our "complete relief' patients and eight of our "improved" patients had negative two-position arteriograms. Had we insisted upon positive angiographic findings these patients would have been denied operative relief. Approximately half of the 11 phlebographic examinations showed an abnormality. Phlebography, however, was limited to patients with edema or venous collateralization around the shoulder girdle since even the positive phlebograms did not alter our method or management. helpful andwe and we as itit is is helpful often confusing confusing as is as as often Phlebography is Phlebography now rarely use it. 3. Electromyography is not often critical but does aid
S.S.
FIG. 7. (Top) Phlebogram shows thrombosis of left subclavian and axillary veins with phlegmasia cerulea dolens. (Bottom) Normal right
veins. Heparin treatment was successful.
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5. Transaxillary first rib resection, with removal of cervical rib when present is the best operation. The most reliable decompression of the brachial plexus is by removal of the floor of the compression area by resection of the first rib. The transaxillary approach of Roos has the advantage of simplicity, directness, no muscles are cut and convalescense is rapid. It is a deep exposure and requires the development of some experience. Once this is learned it is easier than the posterior approach, less dangerous to the artery than the supraclavicular12 and more direct than the subclavicular route.24 A cervical rib can usually be removed through the axilla after the first rib is out. If there is undue difficulty a secondary supraclavicular incision may be used. Removal of the cervical rib along may not completely relieve symptoms and first rib resection should therefore be
done simultaneously.
Illustrative Case Report Case 3. A 44-year-old woman underwent removal of a cervical rib 3 years previously with relief of anterior neck and shoulder pain but continuation of posterior arm pain
radiating down into the hand. Angiography showed no vascular constriction, although the pulse was absent with the arm elevated. (The contralateral asymptomatic arm
FIG. 8. (Top) Cervical rib at arrows; (Bottom) Slight stenosis and poststenotic dilatation of subclavian artery. -
4. Non-operative treatment relieves most patients; operative decompression is indicated for a minority. Most writers do not emphasize the large number of less severe cases which respond to non-operative treatment. Sixty-three per cent of our patients did well with exercises and temporary drug relief while only a minority (37%) required surgery. The 7% operative failure rate was not surprising in view of the difficulty of differential diagnosis. The 36% who obtained partial but not complete relief do concern us. These patients were relieved of most of their symptoms but still did not have a perfectly normal arm. Either the reports of others are overly optimistic or their followups are poor or our treatment is not as good as theirs. Our own ideas have required modification after careful retrospective examination of results and we suspect that statements of 100% good results by others are not critical. Either way we have learned not to promise more than can be delivered to the patient. Fortunately m.B. the mortality rate is nil and complications are few and FIG. 9. (Top) Unusual finding of kink in subclavian artery, arm at side. temporary. (Bottom) The artery straightents to normal with arm elevated.
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plaints of "failed" patients who continue to complain afterwards will eventually discourage this attitude. References
FIG. 10. Cutting the transverse carpal ligament at wrist through a Z-incision to decompress the median nerve.
also had similar pulse cut-off upon elevation.) Secondary operation consisted of supraclavicular removal of the medial half of the clavicle along with the subclavius muscle, a remnant of the scalene muscle and the first rib. Her postoperative course was uneventful and she was asymptomatic at 9 months. Comment. It was necessary to add first rib resection to removal of the cervical rib to effect complete relief. Should sympathectomy be required, it may be easily done by a transpleural approach via the third interspace using the same incision. 6. Carpal tunnel decompression should be done at the
time when needed. If there is any question about lysis of the transverse carpal ligament it should be done at the same time to avoid the necessity for a second hospitalization for the wrist operation. Lord emphasized the concomitant carpal tunnel syndrome in his report on 123 patients. Seventeen had concomitant carpal tunner syndrome and 5 required two separate operations (thoracic outlet decompression plus later section of the transverse carpal ligament at the wrist).19 Two patients in our series had accompanying carpal tunnel syndrome and required later secondary operative relief to produce complete cure. An example is a 44-year-old woman with a 4 year history of numbness in the hand which awakened her at night and interfered with
same
her secretarial work. Some edema was also noticed and led to resection of the first rib for thoracic outlet syndrome. Shortly thereafter pain recurred It was relieved by section of the transverse carpal ligament. 7. Operation is relatively safe. Absence of mortality is notable in this series as well as other series4'11'14'20'32'35'41 and complications are few and temporary. This allows operation to be recommended when needed. It also will allow a non-critical surgeon to advocate surgery for some patients who do not really requires this, but the com-
1. Adson, A. W. and Coffey, J. R.: Cervical Rib: A Method of Anterior Approach for Relief of Symptoms by Division of the Scallenus Anticus, Ann. Surg., 85:839, 1927. 2. Barrash, J. M.: (Letter), N. Engl. J. Med., 287:568, 1972. 3. Blank, R. H. and Connar, R. G.: Arterial Complications Associated with Thoracic Outlet Compression Syndrome, Ann. Thorac. Surg., 17:315, 1974. 4. Bricken, W. M.: Brachial Plexus Pressure by the Normal First Rib, Ann. Surg., 85:858, 1927. 5. Clagett, 0. T.: Presidential Address: Research and Prosearch, J. Thorac. Cardiovasc. Surg., 44:153, 1962. 6. Coote, H.: Exostosis of the Seventh Cervical Vertebra, Surrounded by Blood Vessels and Nerves, Lancet, 1:360, 1861. 7. Cox, W. A., Buker, R. H. and Seitter, G. III: First Rib Resection for Thoracic outlet Compression Syndrome, Am. Fam. Phys., 9:140, 1974. 8. Dale, W. A.: Thoracic Outlet Syndrome, J. Tenn. Med. Assoc., 64:941, 1971. 9. Dale, W. A. and Lewis, M. R.: Management of Ischemia of the Hand and Fingers, Surgery, 67:62, 1970. 10. Eden, K. C.: The Vascular Complications of Cervical Ribs and First Thoracic Rib Abnormalities, Br. J. Surg., 27:11, 1939. 11. Ferguson, T. B., Burford, T. H. and Roper, C. L.: Neurovascular Compression at the Superior Thoracic Aperture: Surgical management, Ann. Surg., 167:573, 1968. 12. Graham, G. G. and Lincoln, B. M.: Anterior Resection of First Rib for Thoracic Outlet Syndrome, Am. J. Surg., 126:803, 1973. 13. Halsted, W. S.: An Experimental Study of Circumscribed Dilation of an Artery Immediately Distal to a Partially Occluding Band, and Its Bearing on the Dilation of the Subclavian Artery Observed in Certain Cases of Cervical Rib, J. Exp. Med., 24:271, 1916. 14. Hamlin, H. and Percora, D.: Subclavicula Segmental Resection of First Rib for Correction of Subjacent Neurovascular Compression, Am. J. Surg., 117:754, 1969. 15. Judy, K. L. and Heymann, R. L.: Vascular Complications of Thoracic Outlet Syndrome Am. J. Surg. 123:521, 1972. 16. Krogness, K.: Ulnar Trunk Conduction Studies in the Diagnosis of the Thoracic Outlet Syndrome, Acta. Chir. Scand., 139:597, 1973. 17. Lang, E. K.: Arteriography and Venography in the Assessment of Thoracic outlet Syndromes, South. Med. J., 65:129, 1972. 18. Longo, M. F., Clagett, 0. T. and Faribairn, J. F.: Surgical Treatment of Thoracic Outlet Compression Syndrome, Ann. Surg., 171:538, 1970. 19. Lord, J. W.: Thoracic Outlet Syndrome: Current Management, Ann. Surg. 173:700, 1971. 20. Lord, J. W. and Rosati, L. M.: Thoracic Outlet Syndromes, Clinical Symposia, Ciba, 23, 1971. 21. McCleery, R. S., Kesterson, J. E., Kirtley, J. A. and Love, R. B.: Subclavius and Anterior Scalene Muscle Compression as a Cause of Intermittent Obstruction of Subclavian Vein, Ann. Surg., 133:588, 1951. 22. Murphy, J. B.: Case of Cervical Rib with Symptoms Resembling Subclavian Aneurysm, Ann. Surg., 41:399, 1905. 23. Naffziger, H. C. and Grant, W. T.: Neuritis of the Brachial Plexus Mechanical in Origin: The Scalenus Syndrome, Surg. Gynecol. Obstet., 67:722, 1938. 24. Nelson, R. M. and Davis, R. W.: Thoracic Outlet Compression Syndrome, Ann. Thorac. Surg., 8:437, 1969. 25. Ochsner, A., Gage, M. and DeBakey, M.: Scalenus Anticus (Naffziger) Syndrome, Am. J. Surg., 28:669, 1935. 26. Peet, R. M., Hendricksen, J. D., Anderson, T. P. and Martin, G. M.: Thoracic Outlet Syndrome: Evaluation of a Therapeutic Exercise Program, Proc. Staff Mtg., Mayo Clinic, 31:281, 1956. 27. Phalen, G.: Reflections on 21 Years' Experience with the Carpal Tunnel Syndrome, JAMA, 212:1365, 1970.
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28. Raphael, M. J., Moazzez, K. and Offen, D. N.: Vascular Manifestations of Thoracic Outlet Compression: Angiographic Appearances, Angiology, 25:237, 1974. 29. Rob, C. G. and Standeven, A.: Arterial Occlusion Complicating Thoracic Outlet Compression Syndrome, Br. Med. J., 2:709, 1958. 30. Roeder, D. K., McHale, J. J., Shepard, B. M. and Ashworth, H. E.: First Rib Resection in the Treatment of Thoracic Outlet Syndrome: Transaxillary and posterior Thoracoplasty Approaches, Ann. Surg., 178:49, 1973. 31. Roos, D. B.: Transaxillary approach for First Rib Resection to Relieve Thoracic Outlet Syndrome, Ann. Surg., 163:354, 1966. 32. Roos, D. B.: Experience with First Rib Resection for Thoracic Outlet Syndrome, Ann. Surg. 173:429, 1971. 33. Roos, D. B. and Owens, J. C.: Thoracic Outlet Syndrome, Arch. Surg., 93:71, 1966. 34. Rosati, L. M. and Lord, J. W.: Neurovascular Compression Syndromes of the Shoulder Girdle, Modern Surgical Monographs, New York, Grune & Stratton, Inc., 1968.
35. Sanders, R. J., Monsour, J. W. and Baer, S. B.: Transaxillary First Rib Resection for Thoracic Outlet Syndrome, Arch. Surg., 97:1014, 1968. 36. Schein, C. J.: A Technique for Cervical Rib Resection, Am. J. Surg., 121:623, 1971. 37. Schein, C. J., Haimovici, H. and Young, H.: Arterial Thrombosis Associated with Cervical Ribs: Surgical Considerations, Surgery, 40:428, 1956. 38. Telford, E. D. and Stopford, J. S. B.: The Vascular Complications of the Cervical Rib, Br. J. Surg., 18:559, 1937. 39. Urschel, H. C., Paulson, D. L. and McNamara, J. J.: Thoracic Outlet Syndrome, Ann. Thorac. Surg., 6:1, 1968. 40. Urschel, H. C. and Razzuk, M. A.: Management of the Thoracic Outlet Syndrome, N. Engl. J. Med., 286:1140, 1972. 41. Urschel, H. C. and Razzuk, M. A.: (Letter), N. Engl. J. Med., 287:567, 1972. 42. Urschel, H. C., Razzuk, M. A., Hyland, J. W., et al.: Thoracic Outlet Syndrome Masquerading as Coronary Artery Disease (Pseudoangina), Ann. Thorac. Surg., 16:239, 1973.
DISCUSSION
The provocative tests which are not widely known must be applied to patients with shoulder arm syndromes. These include the Adson's maneuver, the costoclavicular maneuver, and hyperabduction. When the thoracic outlet syndrome is present, these tests will commonly precipitate symptoms and/or produce compression of the subclavian artery which can be detected by obliteration of the radial pulse and the production of a bruit in the infraclavicular region. The implication we assume is that the median cord of the brachial plexus which is immediately adjacent to the subclavian artery is also compressed. It is this neurological ramification that gives rise to the ulnar nerve which carries fibers of C-8 and T-1. There are also three objective tests (namely, nerve conduction velocities, nystagmagraphy and finger plethysmagraphy) which in my experience have added significantly to the diagnosis of this condition. Furthermore, when they are positive, the results of rib resection are likely to be satisfactory. The latter two tests are performed when the patient is carrying out the provocative maneuvers. The casual observer is commonly impressed with those features of personality which tend to label these patients as neurotics with a multitude of psychosomatic complaints. The fact is that most patients have been to several physicians without obtaining adequate pain relief. They look well, but function poorly and are frequently suspected to be malingerers. Although their stories are often difficult to unravel, the objective studies have helped significantly. Regarding the technique of a first rib resection, we have found that suction drainage is useful to reduce the likelihood of postoperative adhesions which may result in reappearance of symptoms. In many instances we also recommend transection of the posterior as well as the median and anterior scalene muscles in patients whose primary complaints are headache and neck pain.
DR. JERE W. LORD, JR. (New York): My comments, in stead of agreeing with everything that Dr. Dale says in other areas, is somewhat critical, although not of his approach to this problem. His workup is probably the most thorough of any surgeon in this country. The patients are studied carefully, are not rushed into an operation, but are seen by consultants, have electromyographic studies, and many other tests. What really disturbs me is that only 57% obtained excellent results and 43% were either fair or poor. If we were able to diagnose these patients accurately, then we should have a higher percentage of excellent results. The second feature is that Dr. Dale, who is an outstanding vascular surgeon, observed that only 5% of the patients studied had arterial and venous problems. All of the other symptoms were on a neurological basis. Roos has operated upon more than 400 patients and of these only 6% were vascular; 94% were neurological. To have 95% of the patients operated upon for neurological symptoms only is a worrisome thing to me. I remember in the late 30s and early 40s, when section of the scalenus anticus muscle was a popular procedure and was approved of highly by some of the important members of this Association. Later the procedure fell into disrepute around the nation for so many poor results were noted. I am deeply concerned that the excellent operative technique of Roos and Owens of transaxillary resection of the first rib may also in another five or ten years all into disfavor not because the technique is not excellent but because the selection of patients is so difficult.
My colleagues and I operate only upon some five to six patients a for the thoracic outlet syndrome and most of these are on an arterial or venous basis. year
DR. HILARY H. TIMMIs (Royal Oak, Michigan): I would like to congratulate Dr. Dale on the clinical review of his cases of thoracic outlet syndrome and describe a few observations we have derived from the surgical management of 175 patients with this problem. First of all, let me state emphatically that the vast majority of these patients have neurological, rather than vascular symptoms. The response to treatment depends to a great extent on what precipitated the syndrome. It would appear that many have an anatomic predisposition to it, and with trauma, sometimes relatively minor, they begin to have chronic pain.
Hyperextension injuries are especially pernicious and we suspect result in injury to the scalene musculature. The concept of thoracic outlet syndrome has been embraced hesitantly in many instances because of the protean symptomatic manifestations. The classical shoulder arm pain and paresthesias of the hand are common presenting complaints, but by no means the only ones. In some of these patients headache and neck pain predominate, whereas others complain primarily of chest pain which is often confused with angina pectoris. Still another group has syncopy as the primary manifestation with thoracic outlet compression with dizziness and tinnitus that are either accentuated or induced by hyperabduction.
DR. W. ANDREW DALE (Closing discussion): Dr. Lord and I have discussed these problems many times. I was surprised, when I carefully evaluated these patients by a retrospective study, that many whom I thought had excellent results, and had so classified them in my own mind, actually didn't when I looked at my own followup notes. So it has made me more objecative and i now realize that all don't really obtain A-1 excellent results. In answer to the comment about the embolization from subclavian pressure, the paper to which you refer dealt with 36 patients who had ischemic problems in the hand due to a variety of causes (Dale, W. A., Lewis. M. R.: Management of Ischemia of the Hand and Fingers, Surgery, 67:62, 1970.). There were 11 patients with arterial embolism as well as the one mentioned here. Dr. Timmis, I am in general agreement with you. It is important to emphasize the variability of symptoms. I agree that many of these patients are "kooky", if that's the word you used. The delayed approach and general conservatism is directed toward avoiding operation upon patients who have primarily psychosomatic problems, yet the pain and discomfort of thoracic outlet syndrome often mimicks this since physical signs are often absent. I agree that the technique should be radical, in the sense that it's important that all of the rib be removed.
DURING the past 7 years an integrated concept of management of thoracic outlet compression syndrome has been developing which produces good to excellent results in most patients. Numerous articles and increasing numbers of operations attest to widespread interest in the problem which 20 years ago was barely known. There are still unanswered questions relating to pathogenesis, misunderstanding of the clinical syndrome and only partial agreement upon indications and techniques of management. This retrospective study of 153 extremities in 149 patients is discussed in the light of our experience and the background of the reports of others and is particularly directed toward the continuing development of a rational method of overall management. Our experience with 153 upper extremities in 149 patients (1966-74) is summarized in Tables 1-5. Specifically excluded are 15 patients who eventually proved to have carpal tunnel syndrome alone. Follow-up range D from a month to 8 years. Surgeons do not usually discuss cases which do not require operation but since most people with thoracic outlet syndrome fall into the non-surgical category they are included here. Presented at the Annual Meeting of the Southern Surgical Association, December 9-11, 1974, Boca Raton, Florida.
From the Department of Surgery, Vanderbilt University School of Medicine, St. Thomas Hospital and Baptist Hospital, Nashville, Tennessee
Present Clinical Management Patients suspected of thoracic outlet syndrome are initially examined with emphasis upon the history of pain, paresthesias, edema and motor dysfunction (Fig. 1). Known aggravating factors such as injury, rib anomalies, unusual positions as well as general health factors are noted. Examination is directed toward tenderness, masses and bruits in the neck along with pain or pulse cut-off by arm position change. Sensory and motor tests, peripheral pulses, and temperature examination are also done. If the diagnosis of thoracic outlet syndrome (TOS) seems likely, shoulder girdle strengthening exercises (Table 6) are explained and the patient is asked to follow this program regularly for three weeks. Tranquilizers or sedatives to interrupt the cycle of nervous and muscular tension are often prescribed along with warm tub baths to promote relaxation of the muscles of the neck and shoulder girdle. Occasional patients are made worse by exercises and are warned to discontinue should this occur. During this three week period electromyography is done, the cervical spine and chest are x-rayed for anomalies, and a stress electrocardiogram and cardiac consultation are obtained if there is a component of chest pain. At the next office visit the results of exercise and the studies are evaluated and the patient either continued on nonoperative therapy, referred for cardiac therapy, or scheduled for carpal ligament lysis. If symptoms are not relieved there is given a week trial of cervical halter traction as an out-patient in the Physical Therapy Department. This does not help thoracic outlet syndrome but usually benefits cervical disk pressure and is therefore of differential diagnostic benefit.
575
576 Non-operated
Operated
Total
29 68 4 22 21 30 15 5
14 42 1 9 24 14 5 1
43 110 5 31 45 44 20 6
Plain x-ray: cervical rib 1st rib anomaly Anteriogram: abnormal Phlebogram: abnormal
97
56
153
Electromyogram: shoulder abnormality elbow abnormality wrist abnormality no abnormality
< 20 21-30 31-40 41-50 51-60 >60
Total
Should severe symptoms continue, hospitalization is arranged. Two-position subclavian angiograms and in some cases phlebograms are obtained. Neurosurgical consultation is requested and myelography if indicated. If thoracic outlet syndrome continues as the diagnosis the patient is offered (but not urged) brachial plexus decompression by the appropriate procedure and is advised of the expected chance of relief along with that of failure. By this time it is believed that other causes of the symptoms have been ruled out and that nonoperative therapy has been unsuccessful; most patients now request operation. Operations are therefore reserved for patients who continue to have symptoms and do not respond to lesser measures over a period of time. Occasionally, the symptoms may be so acute that immediate operative decompression is warranted. This occurs when pain of a severe degree necessitates opiates, or if the vascular structures are severely involved or become thrombosed. Method The best method to decompress the neurovascular bundle is removal of the first rib along with cervical rib if that is present. At least 4 approaches to the first rib are possible but the transaxillary is easiest and produces less pain and fewer complications once the technique is mastered. The patient is placed in the lateral thoracotomy position and the table later rolled back about 30-40o. The arm is sterilely draped into the field to allow traction upon it (Fig. 2). TABLE 2. Clinical Syndrome in 153 Extremities
History pain paresthesia motor weakness edema Examination pain in AER pulse cut-off
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TABLE 3. Laboratory Findings
TABLE 1. 153 Extremities of 149 Patients
Male Female Age:
Ann. Surg.
DALE AND LEWIS
Total
Non-operated
Operated
97 63 17 14
56 26 18 11
153 89 35 25
14 21
12 20
26 (17%) 41 (27%o)
(100%) (58%) (23%) (16%)
Non-operated
Operated
Total
5 0
11 1
16 (12%) (1%)
2 of 5 (40%)
13 of 29 (45%) 15 of 34 (44%)
0 of 5 (0%o)
6 of 8 (75%)
6 of 13 (46%)
1
4
5
1
0
1
3
5
8
8
15
23
(400o of 38 were abnormal)
A transverse incision is made just below the axillary hairline and dissection from pectoralis major to latissimus dorsi muscle is deepened to the rib cage and then upward into the axilla until the vessels are encountered as they pass over the superior edge of the first rib. The key to a safe and efficient operation is the exposure provided by elevation of the shoulder girdle by upward traction by an assistant. Several methods of traction have been tried, including attachment of the arm to a movable pole for elevation and similar attachment to an overhead orthopedic traction device. The best exposure is obtained by a vigorous assistant holding the wrist and forearm in a hammerlock10 and pulling upward by leaning back to lift the neurovascular bundle off the first rib. Assistants may be alternated at 10 minute intervals. Approximately 20 minutes of exposure is currently required for careful dissection and removal of the first rib.* The sensory nerve crossing the axillary operative field is recognized and divided since an area of anesthesia on the medial upper arm is preferable to postoperative neuritic pain. The anterior scalene muscle is isolated at its attachment to the superior border of the first rib and divided. The first rib is dissected extraperiosteally to avoid regeneration. The dissection is carried out not only by curved, sharp periosteal elevators and scissors but also by the operator's finger which is more sensitive than steel instruments and is used wherever possible. The long thoracic nerve lying on the lateral rib cage is avoided to prevent scapular "winging" if injured. The rib is resected posteriorly near the transverse process of the vertebra *We have personally participated in this retraction and recommend that every surgeon proposing to do this procedure should familiarize himself with the problem similarly.
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THORACIC OUTLET SYNDROME OFFICE INTERVIEW XRAY NECK XRAY CHEST
ELECTROMYOGRAM CARDIAC STUDIESEXERCISE: 3 WEEKS FIG. 1. Flow pattern for current management of patients with thoracic outlet syndrome.
CERVICAL TRACTION: I WEEK
RELIEF
HOSPIT,AL
I
2 POSITION ARTERIOGRAM PH LEBOGRAM NEUROSURGICAL CONSULT-t? MYELOGRAM
OPERATION
57% EXCELLENT 36% PARTIAL 7 % FAILURE -* FAILURE semi-upright chest film is made in the Recovery Room to be certain that a pneumothorax is not overlooked. Secondly, the patient is encouraged to begin full overhead arm motion on the day following surgery and the Physical Therapy Department is enlisted to aid this maneuver
and anteriorly at its junction with the rib cartilage (Fig. 3). During the rib resection a special brachial plexus shield is placed between the rib cutter and the brachial plexus to protect it. Considerable help has been available recently from a newly developed extra-long doubleaction, thin-beaked rib rongeur which is superior to others which were previously available.* Resection of the rib posteriorly is more important than at its anterior junction with the cartilage. The operator looks to see if the brachial plexus impinges upon the cut end of the rib, feels for rough spicules, and lowers the arm to the side while two fingers are placed in the resected rib bed to be certain that decompression is adequate. If the underlying pleura has been opened the resultant pneumothorax is easily managed by placing a small catheter and sucking on this as it is withdrawn after the wound is closed in layers. If the pleura has not been entered a small Penrose drain is left in place for 24 hours. This is not placed if the pleura has not been opened for fear of direct communication and resultant pneumothorax. The operation requires 40 to 90 minutes, being more difficult in heavily muscled patients. Blood loss is minimal and no transfusion has ever been needed. Two points are stressed in postoperative care. First, a
should it prove necessary. A cervical rib is often accessible through the axillary approach after removal of the first rib (Fig. 4). If there is difficulty or if the patient is large or obese a secondary supraclavicular incision may be used (one in this series).* Illustrative Case Reports Case 1. A 44-year-old woman had vague pain in her right arm near the elbow with weakness of grip with incoordination. There were no positive physical findings nor x-ray abnormalities. Electromyography showed delay in nerve conduction both at the elbox and wrist. Exercises did not relieve the symptoms. Transaxillary first rib resection was performed with concomitant carpal tunnel release. Twenty-one months after operation she had no pain but said that her right upper extremity was so weak that she was "hardly able to work." There was some demonstrable weakness in the grip on that side. Comment. Should this patient be classified as an excellent result or as improvement? There are a combination
*This rib rongeur is available from Codman and Shurtleff, Pacella Drive, Randolph, Mass 02268.
*The 1971 description of operative technique for cervical rib moved by Clarence J. Schein is excellent.37
re-
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Ann. Surg. * May 1975
PI
.s:
FIG. 3A. Postoperative appearance after first rib resection. Clips placed during concomitant sympathectomy.
FIG. 2. Position for transaxillary resection of first rib. Arm is and draped into the field. Inset: Excised rib.
prepared
of factors which may suggest to the patient that she has good reason to avoid work at a boring job. She was classified as "improved." Case 2. A 33-year-old woman had transaxillary resection of the first rib for relief of shoulder and arm pain of 6 months duration associated with paresthesias in the left shoulder and arm. The preoperative pulse cut-off during elevation was changed and she obtained relief. The TABLE 4. Results of 56 Operations in 54 Patients
Complete Relief
Improved
20 14 49 Transaxillary 1st rib resect. + clavicle resect. 2 + cervical rib resect. 3 1 + carpal lysis 4 2 (subtotal: 1st rib removal) (29 = 60%o) (17 = 35%) 4 Resection cervical rib +scal1 enectomy 3 3 Scalenectomy only 2 Total 32 (57%) 20 (36%)
Failure
were
preoperative arteriogram had shown narrowing. Electromyography was normal. Nine months later there was recurrence of pain in the left lateral neck. Electromyography was again negative. Cervical myelography was negative. A previously recognized cervical rib on the contralateral (asymptomatic) side was still present and raised a question as to whether there might be a fibrous band on the painful side although x-ray again did not show any cervical rib or other anomaly of the bony cage. Thirteen months following the original operation the left neck was explored through a supraclavicular approach to be certain that there was no soft tissue band compressing the brachial plexus. Nothing was found. The medial half of the clavicle was resected and an additional amount of anterior scalene muscle was removed. She again had relief of pain. Two years later she was rehospitalized for recurrence of pain in the left neck and shoulder. There were no positive findings and she was treated symptomatically. Comment. This illustrates inability of her internist, a neurosurgeon and ourselves to obtain complete relief despite two operative procedures. The patient is classed as improved. Her symptoms are inconsistent, but it is uncertain whether operation had any specific decompressive effect.
2
1 (3
6%)
=
1
4 (7%)
Results There was some relief of symptoms by one method or another in 97% of the extremities (Table 4). Among those having surgery, 93% obtained complete or partial relief while 7% were failures in that symptoms were unchanged. None were made worse. There were no deaths. Complications are listed in
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I
FIG. 3B. Extra long double action rongeur has thin beak for removal of posterior end of rib.
Table 5. All were temporary except for one patient who had a permanent limitation of elevation of the shoulder following inability to mobilize the shoulder properly postoperatively. Discussion The twisting road which has led to our present understanding of thoracic outlet syndrome began over a hundred years ago when the first clinical diagnoses were recorded and an early attempt was made to remove the first rib by Coote' in 1861.12 Prominent surgeons successively became interested in the problem, and in 1905, John B. Murphy of Chicago resected a cervical rib which had produced a subclavian aneurysm.22 By 1916 Halsted was able to find records of 716 patients with cervical ribs; he conducted experiments to determine the cause of the occasional aneurysm of the overlying subclavian artery. 13 Telford and Stopford demonstrated how the brachial plexus and subclavian artery could be compressed by the first thoracic rib and reported 6 patients who were relieved of symptoms following its resection.38 Adson, in 1927, reviewed the subject extensively and introduced his clinical test.' The role of the scalene anticus muscle in neurovascular compression was developed further by Naffziger and Grant23 and by Ochsner, Gage and DeBakey in 193525 and succeeding years saw other compression syndromes described. Peet and associates, in 1956, suggested that all of these compression syndromes might be termed thoracic outlet syndrome;26 this term was later modified by Rob and Standeven to thoracic outlet compression syndrome, which includes all synTABLE 5. Complications Deaths: 0 Infections: 0 Temporary long thoracic nerve injury 2 Acute bursitis of shoulder Stiff shoulder Pneumothorax requiring aspiration in recovery room Wound hematoma
2 2 2 1
A.
~POST- 0_
C.L
FIG. 4. Cervical rib at arrow was removed along with first rib by transaxillary approach.
dromes of compression of the neurovascular structures of the upper extremities.29 The term "neurovascular compression syndromes of the shoulder girdle" used by Rosati and Lord34 is more correct terminology but is bulky and since "thoracic outlet syndrome" has now been generally accepted (even by these authors) it will be used here. The significant failure rate of scalenectomy alone led to efforts to achieve greater decompression. McCleery and associates, in 1951, added removal of the costocoracoid membrane and subclavian muscle2 while Rosati and Lord, in 1961, emphasized claviculectomy.3 Resections of the first rib had been reported earlier4 and in 1962, Clagett redirected attention to this when he reported his good results after resection of the first rib via the posterior approach.5 Ferguson, Buford and Roper confirmed this in 12 other patients" and Clagett later increased his reported series to 44 successful first rib resections.18 Resection of the first rib via the axillary approach was described in 1966 by Roos31 whose series has been enlarged to over 450.32 This route allows removal of the rib without cutting muscles and has been productive of good
DALE AND LEWIS
580
Ann.
Surg. May 1975 -
TABLE 6. Shoulder-Girdle Exercises for Thoracic-Outlet Syndrome* At the beginning, each exercise is done 10 times in succession twice a day. As the shoulders and neck gain strength, the number of times each exercise is done consecutively can be increased. The six exercises follow: 1. Stand erect with the arms at the sides, holding in each hand a 2-pound weight (sandbags, or bottles, jars or sacks filled with sand). (a) Shrug the shoulders forward and upward. (b) Relax. (c) Shrug the shoulders backward and upward. (d) Relax. (e) Shrug the shoulders upward. (f) Relax and repeat. 2. Stand erect with the arms out straight from the sides at shoulder level; hold a 2-pound weight in each hand (palms should be down). (a) Raise the arms sideways and up until the backs of the hands meet above the head (keep elbows straight. (b) Relax and repeat. Note: As strength improves and exercises 1 and 2 become easier, weights should be made heavier; increase to 5 and later to 10 pounds. 3. Stand facing a corner of the room with one hand on each wall, arms at shoulder level, palms forward, elbows bent and abdominal muscles contracted. (a) Slowly let the upper part of the trunk lean forward and press to the chest into the corner. Inhale as the body leans forward. (b) Return to the original position by pushing out with the hands. Exhale with this movement. 4. Stand erect with the arms at the sides. (a) Bending the neck to the left, attempt to touch the left ear to the left shoulder without shrugging the shoulder. (b) Bending the neck to the right, attempt to touch the right ear to the right shoulder without shrugging the shoulder. (c) Relax and repeat. 5. Lie face down with the hands clasped behind the back. (a) Raise the head and chest from the floor as high as possible while pulling the shoulders- backward and the chin in. Hold this position for a count of three. Inhale as the chest is raised. (b) Exhale and return to the original position. (c) Repeat. 6. Lie down on the back with arms at the sides, with a rolled towel or small pillow under the upper part of the back between the shoulder blades and no pillow under the head. (a) Inhale slowly and raise the arms upward and backward overhead. (b) Exhale and lower the arms to the sides. (c) Repeat 5 to 20 times.
*From Fairbain, Juergens, Spittell, Peripheral Vascular Diseases, W. B. Saunders, Philadelphia 1972, Page 473.
results with few complications. Excision of the first thoracic rib removes the floor of the compression compartment and allows the neurovascular bundle to drop downward away from the overlying and enclosing structures.
Pathogenesis. The narrow space composed of firm or rigid structures through which course the nerves and vessels from the neck to the axilla easily causes pressure. The addition of congenital anomalies of ribs and muscles compounds this, as does any unusual position which is persistent, such as hyperabduction at work or during sleep, an injury, degenerative changes, and muscle spasm. Harold C. Urschel's diagram (Fig. 5) appears to be a reasonable explanation of how pressure occurs.40 Lord and Rosati have enumerated 5 factors which may contribute to pressure, namely: 1) congenital anomalies, muscles anterior scalene middle scolene
fascia bone costocoracoid membrane cervical rib clavicle
subclavius
pectoralis minor
vascular symptoms (5-10%) vein artery edema ischemia collaterals coldness cyanosis necrosis
nerve symptoms (98%)
PAIN 100% paresthesias 58% weakness 23%
2) static size or shape of compressing structures, 3) dynamic changes with motion, 4) trauma, including fractures and "whiplash," and 5) the aging processes of arteriosclerosis and muscle atrophy.20 The actual reason why some people develop pressure symptoms while most do not is unclear. The common occurrence in middle age (78% were 21-50-years-old in our series) and in women (72%) has suggested that muscle atrophy combined with increasing weight accounts for many instances. However, this explanation collapses with examination since age and obesity should cause even further loss of muscle tone, yet the incidence of symptoms diminishes as age advances. Cervical rib is said to occur in 1% of the population and to be symptomatic in 10%o of instances. Twelve per cent of our patients had cervical ribs and another one had an anomaly of the first rib. This crowding of the space understandably causes compression. Thoracic outlet symptoms not infrequently begin after injury, automobile whiplash accidents being the most common form in the United States. Sanders, Monsour and Baer noted that 52% of their 58 patients featured this,35 while Roos and Owens reported it in 34% of 138 patients. 3 The actual incidence is difficult to obtain since close questioning often brings out some memory of a neck or shoulder injury, in these patients which may be overlooked. The following conclusions are based upon review of our patients as well as the reports of others and are offered with knowledge that full documentation of these ideas is not possible and that some may prove to be erroneous.
FIG. 5. Thoracic outlet syndrome. Causes of pressure plexus, modified from Urschel.39
upon
brachial
1. Diagnosis is more dependent upon history than examination. Some form of pain is invariable. It is often
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and the patient finds localization difficult. It is not pin-pointed to the shoulder or elbow and may lead the inexperienced clinician to conclude that it is not real. The pain is due to nerve pressure and not to ischemia as has been thought in the past. Anterior chest pain may also occur. This has been termed pseudo-angina by Urschel and associates who differentiated brachial plexus pressure as it cause in 44 patients. Another 13 patients had both thoracic outlet syndrome and angina due to coronary arterial disease. They used coronary arteriography and electromyography to differentiate.42 Paresthesias are common (58% here) and more often involves the ulnar distribution, but also may be general. Motor incoordination (23%) may be manifest by dropping objects, or weakness of grip. Edema (16%) in this group was chiefly by history of enlarged finers and hands and was not usually pitting and demonstrable. Lack of postive physical findings was noted. Only a minority (17%) had pain when the arm was elevated and externally rotated. The Adson test for pulse cut-off was similarly disappointing, frequently resulting in numerous false positives in asymptomatic patients. The subjective nature of pain along with the paucity of objective findings often leads to uncertainly in diagnosis. Restriction of definitive treatment to those with a sure diagnosis will fail to provide available relief of pain to some patients while acceptance for surgery on the basis of loose indications leads to confusions and unnecessary vague
treatment.
A large number of differential diagnoses may be listed but the problem essentially comes down to three questions (Table 7). First, is pain of organic origin? Second, are the symptoms typical of nerve pressure, that is, pain which is widespread and poorly localized, or is the pain in a joint or tendon with local manifestations? The final question is whether the nerve compression exists at the level of exit of the nerves from the cervical vertebra, at the thoracic outlet, at the elbow or at the wrist. All of these pressure points occur, may co-exist and tend to be confuses. In this series no instance of compression at the elbow has been recognized, but 7 of the 59 patients undergoing operation also had lysis of the transverse carpal ligament at the wrist and an additional TABLE 7. Differential Diagnosis 1. Pain (a) is it of organic origin? (b) is it due to nerve pressure? (c) is the pressure; at the vertebral column & thoracic outlet? Elbow? wrist? 2. Common lesions to be ruled out: (a) cervical root pressure by disk; arthritis (b) shoulder "bursitis" (c) occlusion of arteries of wrist or hand (d) carpal tunnel syndrome
581 15 patients who originally were thought to have thoracic outlet syndrome were operated upon for carpal tunnel syndrome as the proper diagnosis (outside of this series). Symptoms of hand ischemia (Raynaud's phenomenon, coldness, or ulceration) are not ordinarily ptoduced by thoracic outlet syndrome but by Raynaud's disease or Raynaud's phenomenon secondary to other problems. In the older literature it is commonly stated that Raynaud's phenomenon may accompany thoracic outlet syndrome but we have not observed such (although we see a good many patients with hand and finger ischemia due to other causes).9 Brachial angiography is the key examination for differential diagnosis in this situation. 2. Major vascular problems are unusual; angiography is not always necessary. Vascular signs have been thought common but our experience denies this since only one arterial and three venous problems attributable to thoracic outlet pressure have occurred in the 8 year time period of this series. The arterial problem8 consisted of axillary thrombosis and required a graft as well as distal decompression (Fig.
6). The three venous cases of phlegmasia cerulea dolens treated by intravenous heparin. Only one of the three required venous thrombectomy (Fig. 7). The small number of serious vascular complications is were
attested by Roos' incidence of 6%,32 Sanders of 12%35
and Urschel's one arterial and 14 venous problems among 400 patients (4%).41 Judy and Heymann in 1972 reported only 53 major vascular complications in the English literature15 beyond the 29 earlier ones of Schein, Haimovici and Young.37
The arterial problems which do occur are generally associated with cervical ribs or other bony anomalies at the thoracic outlet. As long ago as 1939 Eden found only a single such case without a bone abnormality among a total of 42.10 More recently Raphael, Moazzez and Offen reaffirmed this in connection with 7 cases28 and Bland and Connar reported 6 arterial problems associated with cervical rib or first rib abnormalities among their 40 patients operated upon for thoracic outlet syndrome.3 Our patient with an arterial problem had a cervical rib. It is therefore not likely that a vascular complication will occur in the absence of cervical rib or anomalous first rib. This implies that angiography should be done when such bony anomalies are present. The results of twoposition angiography in other patients is less rewarding. Among 34 arteriograms in this series positive findings were limited to 44% of these angiograms. The changes consisted of minor degrees of stenosis due to external compression, often accompanied by a small amount of post-stenotic dilatation (Figs. 7 and 8). No aneurysms nor thromboses were discovered except for the one noted above. This is a considerably smaller percentage than the 70o of 158 patients studied by Land.17 The results of routine angiography have therefore been disappointing
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diagnosis of carpal tunnel syndrome. The 1968 report of Urschel, Paulson and McNamara that pressure slowed nerve conduction with postoperative reversal in 17 patients suggested this might become a critical objective test.39 Krogness studied 5 patients before and after scalenectomy4and first rib resection1 and reported similar findings.16 The electromyogram has not yet been widely accepted; Roos for example has stated that it was unrewarding in his work-up of 1700 patients. Disagreement between its advocates in regard to the effects of
.position is also noted. In the latter part of this series there were 38 patients who had electromyograms; only 40o were abnormal. Positive findings at the shoulder level were infrequent and the chief value of electromyography in our hands is to furnish information regarding never pressure at the wrist, which agrees with Lord's viewpoint.19 We are unable to explain the difference between our experience and that of the advocates of electromyography. But whatever the cause, we cannot rely upon it as a practical objective test for thoracic outlet syndrome at present.
FIG.6. (Top) The axillary artery is sharply compressed at the arrow when the upper extremity is elevated and abducted and this resulted in the distal embolism. (Bottom) The axillary artery appears normal with aA arm in the dependent position. The vein graft was used to bypass the old embolism and secondary thrombosis of the brachial artery. First rib resection and claviculectomy were also done.
and this test did not particularly aid in differential diagnosis or treatment. We now believe it should be used chiefly for patients whose history or physical examination casts suspicion upon the artery or when a bone abnormality is present and that it is not useful for the majority of patients with thoracic outlet syndrome whose symptoms are due to nerve pressure. Eight of our "complete relief' patients and eight of our "improved" patients had negative two-position arteriograms. Had we insisted upon positive angiographic findings these patients would have been denied operative relief. Approximately half of the 11 phlebographic examinations showed an abnormality. Phlebography, however, was limited to patients with edema or venous collateralization around the shoulder girdle since even the positive phlebograms did not alter our method or management. helpful andwe and we as itit is is helpful often confusing confusing as is as as often Phlebography is Phlebography now rarely use it. 3. Electromyography is not often critical but does aid
S.S.
FIG. 7. (Top) Phlebogram shows thrombosis of left subclavian and axillary veins with phlegmasia cerulea dolens. (Bottom) Normal right
veins. Heparin treatment was successful.
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5. Transaxillary first rib resection, with removal of cervical rib when present is the best operation. The most reliable decompression of the brachial plexus is by removal of the floor of the compression area by resection of the first rib. The transaxillary approach of Roos has the advantage of simplicity, directness, no muscles are cut and convalescense is rapid. It is a deep exposure and requires the development of some experience. Once this is learned it is easier than the posterior approach, less dangerous to the artery than the supraclavicular12 and more direct than the subclavicular route.24 A cervical rib can usually be removed through the axilla after the first rib is out. If there is undue difficulty a secondary supraclavicular incision may be used. Removal of the cervical rib along may not completely relieve symptoms and first rib resection should therefore be
done simultaneously.
Illustrative Case Report Case 3. A 44-year-old woman underwent removal of a cervical rib 3 years previously with relief of anterior neck and shoulder pain but continuation of posterior arm pain
radiating down into the hand. Angiography showed no vascular constriction, although the pulse was absent with the arm elevated. (The contralateral asymptomatic arm
FIG. 8. (Top) Cervical rib at arrows; (Bottom) Slight stenosis and poststenotic dilatation of subclavian artery. -
4. Non-operative treatment relieves most patients; operative decompression is indicated for a minority. Most writers do not emphasize the large number of less severe cases which respond to non-operative treatment. Sixty-three per cent of our patients did well with exercises and temporary drug relief while only a minority (37%) required surgery. The 7% operative failure rate was not surprising in view of the difficulty of differential diagnosis. The 36% who obtained partial but not complete relief do concern us. These patients were relieved of most of their symptoms but still did not have a perfectly normal arm. Either the reports of others are overly optimistic or their followups are poor or our treatment is not as good as theirs. Our own ideas have required modification after careful retrospective examination of results and we suspect that statements of 100% good results by others are not critical. Either way we have learned not to promise more than can be delivered to the patient. Fortunately m.B. the mortality rate is nil and complications are few and FIG. 9. (Top) Unusual finding of kink in subclavian artery, arm at side. temporary. (Bottom) The artery straightents to normal with arm elevated.
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plaints of "failed" patients who continue to complain afterwards will eventually discourage this attitude. References
FIG. 10. Cutting the transverse carpal ligament at wrist through a Z-incision to decompress the median nerve.
also had similar pulse cut-off upon elevation.) Secondary operation consisted of supraclavicular removal of the medial half of the clavicle along with the subclavius muscle, a remnant of the scalene muscle and the first rib. Her postoperative course was uneventful and she was asymptomatic at 9 months. Comment. It was necessary to add first rib resection to removal of the cervical rib to effect complete relief. Should sympathectomy be required, it may be easily done by a transpleural approach via the third interspace using the same incision. 6. Carpal tunnel decompression should be done at the
time when needed. If there is any question about lysis of the transverse carpal ligament it should be done at the same time to avoid the necessity for a second hospitalization for the wrist operation. Lord emphasized the concomitant carpal tunnel syndrome in his report on 123 patients. Seventeen had concomitant carpal tunner syndrome and 5 required two separate operations (thoracic outlet decompression plus later section of the transverse carpal ligament at the wrist).19 Two patients in our series had accompanying carpal tunnel syndrome and required later secondary operative relief to produce complete cure. An example is a 44-year-old woman with a 4 year history of numbness in the hand which awakened her at night and interfered with
same
her secretarial work. Some edema was also noticed and led to resection of the first rib for thoracic outlet syndrome. Shortly thereafter pain recurred It was relieved by section of the transverse carpal ligament. 7. Operation is relatively safe. Absence of mortality is notable in this series as well as other series4'11'14'20'32'35'41 and complications are few and temporary. This allows operation to be recommended when needed. It also will allow a non-critical surgeon to advocate surgery for some patients who do not really requires this, but the com-
1. Adson, A. W. and Coffey, J. R.: Cervical Rib: A Method of Anterior Approach for Relief of Symptoms by Division of the Scallenus Anticus, Ann. Surg., 85:839, 1927. 2. Barrash, J. M.: (Letter), N. Engl. J. Med., 287:568, 1972. 3. Blank, R. H. and Connar, R. G.: Arterial Complications Associated with Thoracic Outlet Compression Syndrome, Ann. Thorac. Surg., 17:315, 1974. 4. Bricken, W. M.: Brachial Plexus Pressure by the Normal First Rib, Ann. Surg., 85:858, 1927. 5. Clagett, 0. T.: Presidential Address: Research and Prosearch, J. Thorac. Cardiovasc. Surg., 44:153, 1962. 6. Coote, H.: Exostosis of the Seventh Cervical Vertebra, Surrounded by Blood Vessels and Nerves, Lancet, 1:360, 1861. 7. Cox, W. A., Buker, R. H. and Seitter, G. III: First Rib Resection for Thoracic outlet Compression Syndrome, Am. Fam. Phys., 9:140, 1974. 8. Dale, W. A.: Thoracic Outlet Syndrome, J. Tenn. Med. Assoc., 64:941, 1971. 9. Dale, W. A. and Lewis, M. R.: Management of Ischemia of the Hand and Fingers, Surgery, 67:62, 1970. 10. Eden, K. C.: The Vascular Complications of Cervical Ribs and First Thoracic Rib Abnormalities, Br. J. Surg., 27:11, 1939. 11. Ferguson, T. B., Burford, T. H. and Roper, C. L.: Neurovascular Compression at the Superior Thoracic Aperture: Surgical management, Ann. Surg., 167:573, 1968. 12. Graham, G. G. and Lincoln, B. M.: Anterior Resection of First Rib for Thoracic Outlet Syndrome, Am. J. Surg., 126:803, 1973. 13. Halsted, W. S.: An Experimental Study of Circumscribed Dilation of an Artery Immediately Distal to a Partially Occluding Band, and Its Bearing on the Dilation of the Subclavian Artery Observed in Certain Cases of Cervical Rib, J. Exp. Med., 24:271, 1916. 14. Hamlin, H. and Percora, D.: Subclavicula Segmental Resection of First Rib for Correction of Subjacent Neurovascular Compression, Am. J. Surg., 117:754, 1969. 15. Judy, K. L. and Heymann, R. L.: Vascular Complications of Thoracic Outlet Syndrome Am. J. Surg. 123:521, 1972. 16. Krogness, K.: Ulnar Trunk Conduction Studies in the Diagnosis of the Thoracic Outlet Syndrome, Acta. Chir. Scand., 139:597, 1973. 17. Lang, E. K.: Arteriography and Venography in the Assessment of Thoracic outlet Syndromes, South. Med. J., 65:129, 1972. 18. Longo, M. F., Clagett, 0. T. and Faribairn, J. F.: Surgical Treatment of Thoracic Outlet Compression Syndrome, Ann. Surg., 171:538, 1970. 19. Lord, J. W.: Thoracic Outlet Syndrome: Current Management, Ann. Surg. 173:700, 1971. 20. Lord, J. W. and Rosati, L. M.: Thoracic Outlet Syndromes, Clinical Symposia, Ciba, 23, 1971. 21. McCleery, R. S., Kesterson, J. E., Kirtley, J. A. and Love, R. B.: Subclavius and Anterior Scalene Muscle Compression as a Cause of Intermittent Obstruction of Subclavian Vein, Ann. Surg., 133:588, 1951. 22. Murphy, J. B.: Case of Cervical Rib with Symptoms Resembling Subclavian Aneurysm, Ann. Surg., 41:399, 1905. 23. Naffziger, H. C. and Grant, W. T.: Neuritis of the Brachial Plexus Mechanical in Origin: The Scalenus Syndrome, Surg. Gynecol. Obstet., 67:722, 1938. 24. Nelson, R. M. and Davis, R. W.: Thoracic Outlet Compression Syndrome, Ann. Thorac. Surg., 8:437, 1969. 25. Ochsner, A., Gage, M. and DeBakey, M.: Scalenus Anticus (Naffziger) Syndrome, Am. J. Surg., 28:669, 1935. 26. Peet, R. M., Hendricksen, J. D., Anderson, T. P. and Martin, G. M.: Thoracic Outlet Syndrome: Evaluation of a Therapeutic Exercise Program, Proc. Staff Mtg., Mayo Clinic, 31:281, 1956. 27. Phalen, G.: Reflections on 21 Years' Experience with the Carpal Tunnel Syndrome, JAMA, 212:1365, 1970.
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28. Raphael, M. J., Moazzez, K. and Offen, D. N.: Vascular Manifestations of Thoracic Outlet Compression: Angiographic Appearances, Angiology, 25:237, 1974. 29. Rob, C. G. and Standeven, A.: Arterial Occlusion Complicating Thoracic Outlet Compression Syndrome, Br. Med. J., 2:709, 1958. 30. Roeder, D. K., McHale, J. J., Shepard, B. M. and Ashworth, H. E.: First Rib Resection in the Treatment of Thoracic Outlet Syndrome: Transaxillary and posterior Thoracoplasty Approaches, Ann. Surg., 178:49, 1973. 31. Roos, D. B.: Transaxillary approach for First Rib Resection to Relieve Thoracic Outlet Syndrome, Ann. Surg., 163:354, 1966. 32. Roos, D. B.: Experience with First Rib Resection for Thoracic Outlet Syndrome, Ann. Surg. 173:429, 1971. 33. Roos, D. B. and Owens, J. C.: Thoracic Outlet Syndrome, Arch. Surg., 93:71, 1966. 34. Rosati, L. M. and Lord, J. W.: Neurovascular Compression Syndromes of the Shoulder Girdle, Modern Surgical Monographs, New York, Grune & Stratton, Inc., 1968.
35. Sanders, R. J., Monsour, J. W. and Baer, S. B.: Transaxillary First Rib Resection for Thoracic Outlet Syndrome, Arch. Surg., 97:1014, 1968. 36. Schein, C. J.: A Technique for Cervical Rib Resection, Am. J. Surg., 121:623, 1971. 37. Schein, C. J., Haimovici, H. and Young, H.: Arterial Thrombosis Associated with Cervical Ribs: Surgical Considerations, Surgery, 40:428, 1956. 38. Telford, E. D. and Stopford, J. S. B.: The Vascular Complications of the Cervical Rib, Br. J. Surg., 18:559, 1937. 39. Urschel, H. C., Paulson, D. L. and McNamara, J. J.: Thoracic Outlet Syndrome, Ann. Thorac. Surg., 6:1, 1968. 40. Urschel, H. C. and Razzuk, M. A.: Management of the Thoracic Outlet Syndrome, N. Engl. J. Med., 286:1140, 1972. 41. Urschel, H. C. and Razzuk, M. A.: (Letter), N. Engl. J. Med., 287:567, 1972. 42. Urschel, H. C., Razzuk, M. A., Hyland, J. W., et al.: Thoracic Outlet Syndrome Masquerading as Coronary Artery Disease (Pseudoangina), Ann. Thorac. Surg., 16:239, 1973.
DISCUSSION
The provocative tests which are not widely known must be applied to patients with shoulder arm syndromes. These include the Adson's maneuver, the costoclavicular maneuver, and hyperabduction. When the thoracic outlet syndrome is present, these tests will commonly precipitate symptoms and/or produce compression of the subclavian artery which can be detected by obliteration of the radial pulse and the production of a bruit in the infraclavicular region. The implication we assume is that the median cord of the brachial plexus which is immediately adjacent to the subclavian artery is also compressed. It is this neurological ramification that gives rise to the ulnar nerve which carries fibers of C-8 and T-1. There are also three objective tests (namely, nerve conduction velocities, nystagmagraphy and finger plethysmagraphy) which in my experience have added significantly to the diagnosis of this condition. Furthermore, when they are positive, the results of rib resection are likely to be satisfactory. The latter two tests are performed when the patient is carrying out the provocative maneuvers. The casual observer is commonly impressed with those features of personality which tend to label these patients as neurotics with a multitude of psychosomatic complaints. The fact is that most patients have been to several physicians without obtaining adequate pain relief. They look well, but function poorly and are frequently suspected to be malingerers. Although their stories are often difficult to unravel, the objective studies have helped significantly. Regarding the technique of a first rib resection, we have found that suction drainage is useful to reduce the likelihood of postoperative adhesions which may result in reappearance of symptoms. In many instances we also recommend transection of the posterior as well as the median and anterior scalene muscles in patients whose primary complaints are headache and neck pain.
DR. JERE W. LORD, JR. (New York): My comments, in stead of agreeing with everything that Dr. Dale says in other areas, is somewhat critical, although not of his approach to this problem. His workup is probably the most thorough of any surgeon in this country. The patients are studied carefully, are not rushed into an operation, but are seen by consultants, have electromyographic studies, and many other tests. What really disturbs me is that only 57% obtained excellent results and 43% were either fair or poor. If we were able to diagnose these patients accurately, then we should have a higher percentage of excellent results. The second feature is that Dr. Dale, who is an outstanding vascular surgeon, observed that only 5% of the patients studied had arterial and venous problems. All of the other symptoms were on a neurological basis. Roos has operated upon more than 400 patients and of these only 6% were vascular; 94% were neurological. To have 95% of the patients operated upon for neurological symptoms only is a worrisome thing to me. I remember in the late 30s and early 40s, when section of the scalenus anticus muscle was a popular procedure and was approved of highly by some of the important members of this Association. Later the procedure fell into disrepute around the nation for so many poor results were noted. I am deeply concerned that the excellent operative technique of Roos and Owens of transaxillary resection of the first rib may also in another five or ten years all into disfavor not because the technique is not excellent but because the selection of patients is so difficult.
My colleagues and I operate only upon some five to six patients a for the thoracic outlet syndrome and most of these are on an arterial or venous basis. year
DR. HILARY H. TIMMIs (Royal Oak, Michigan): I would like to congratulate Dr. Dale on the clinical review of his cases of thoracic outlet syndrome and describe a few observations we have derived from the surgical management of 175 patients with this problem. First of all, let me state emphatically that the vast majority of these patients have neurological, rather than vascular symptoms. The response to treatment depends to a great extent on what precipitated the syndrome. It would appear that many have an anatomic predisposition to it, and with trauma, sometimes relatively minor, they begin to have chronic pain.
Hyperextension injuries are especially pernicious and we suspect result in injury to the scalene musculature. The concept of thoracic outlet syndrome has been embraced hesitantly in many instances because of the protean symptomatic manifestations. The classical shoulder arm pain and paresthesias of the hand are common presenting complaints, but by no means the only ones. In some of these patients headache and neck pain predominate, whereas others complain primarily of chest pain which is often confused with angina pectoris. Still another group has syncopy as the primary manifestation with thoracic outlet compression with dizziness and tinnitus that are either accentuated or induced by hyperabduction.
DR. W. ANDREW DALE (Closing discussion): Dr. Lord and I have discussed these problems many times. I was surprised, when I carefully evaluated these patients by a retrospective study, that many whom I thought had excellent results, and had so classified them in my own mind, actually didn't when I looked at my own followup notes. So it has made me more objecative and i now realize that all don't really obtain A-1 excellent results. In answer to the comment about the embolization from subclavian pressure, the paper to which you refer dealt with 36 patients who had ischemic problems in the hand due to a variety of causes (Dale, W. A., Lewis. M. R.: Management of Ischemia of the Hand and Fingers, Surgery, 67:62, 1970.). There were 11 patients with arterial embolism as well as the one mentioned here. Dr. Timmis, I am in general agreement with you. It is important to emphasize the variability of symptoms. I agree that many of these patients are "kooky", if that's the word you used. The delayed approach and general conservatism is directed toward avoiding operation upon patients who have primarily psychosomatic problems, yet the pain and discomfort of thoracic outlet syndrome often mimicks this since physical signs are often absent. I agree that the technique should be radical, in the sense that it's important that all of the rib be removed.
