International Journal of Angiotogy 7:202-205 (1998)

Thoracic Outlet Syndrome: Follow-up on 33 Cases with Regard to Vascular Compression

Barbara S. Lutz, M.D., Branislav Matejic, M.D., Giulio Ingianni, M.D.

Clinic for Plastic and Handsurgery, Ferdinand-Sauerbruch-Clinic, University of Witten-Herdecke, Wuppertal, Germany

Abstract. This fo l low-up study on 33 operat ions per- formed for thoracic outlet syndrome (TOS) proves high ef- ficiency in relieving neurological and arterial symptoms, whereas benefit to venous compression is somewhat less. Twenty-six patients (average age was 36 years) were oper- ated on for TOS, seven of them on both sides. There was a higher incidence in females. All patients showed neurologi- cal symptoms. In 15, operations on various entrapment syn- dromes of the upper extremity were performed previously. Six patients presented with an incomplete resection of the first rib. Arterial compression symptoms were evident in 15 cases, symptoms of venous compression in 14 limbs. All patients underwent a resection of the first rib, bilateral in seven cases, using the axil lary and suwaclav icu lar ap- proach. In seven patients, a cervical rib and scalenus muscles were resected additionally, in three patients bilat- erally. In two cases a neurolysis of the brachial plexus was performed. Using the supraclavicular approach, no compli- cations occurred. In one early patient using the transaxillary approach to a postoperative hemothorax required a revision. Neurological results after surgery showed a total release in 26 limbs (n = 33). In 14 limbs (n = 15) with arterial compression symptoms and in 6 (n = 14) with symptoms of venous compression the operation showed a curative effect.

Introduction

Symptoms resulting from pressure on either the lower trunk of the brachial plexus and/or the subclavian vessels are known as thoracic outlet syndrome (TOS) since Peet et al. [1] first used this term in 1956. Most often it is associated with the presence of congenital f ibromuscular bands [2] or a cervical rib, first thoracic rib abnormalities, supernumer- ary scalene muscles and developmental variations of sca-

Correspondence to: Barbara S. Lutz, M.D., Microsurgery Reconstructive Extremity Center, Dept. for Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, 199, Tung Hwa North Road, Taipei, Taiwan 105, R.O.C.

lene and subclavius muscles or their insertions [3]. A trauma such as the fracture of the clavicle and repetitive misuse of muscles in the upper extremities, shoulder, and neck region may also lead to TOS [4-6]. The accurate diagnosis of TOS is difficult to make and requires exclusion of other disor- ders. Several tests specifically for evaluation of TOS are known [7]. Further examinations [3,7-10] include electro- diagnostic tests, radiography of the chest and cervical spine, duplex ultrasound and Doppler sonography, arteriography and venography, computed tomography (CT), and more re- cently, magnetic resonance imaging (MRI) of the thoracic inlet [11] and intravascular ultrasound [12]. The choice of treatment for TOS is controversial. Good results after physi- cal therapy are known (2,18,37) as well as after surgery [2,10,16-24] With regard to the operative treatment, how- ever, severe injuries during surgery are described [25-27]. This study describes our experiences with the surgical treat- ment of TOS performed in 33 cases.

Material and Methods

Twenty-six patients (18 females and 8 males) with a mean age of 36 years have been operated on for TOS; seven of them underwent bilateral opera- tion. At presentation all patients showed neurological symptoms (Table 1), 12 of whom complained of symptoms of an epicondylitis humeri radialis (EHR). Fifteen of the 26 patients had been operated on previously for carpal

tunnel syndrome (CTS), sulcus ulnaris compression syndrome (SUS), and EHR without being cured (Table 2). A 36 year-old female patient had undergone three operations for CTS (once on the fight side, twice on the left side), two on SUS (once on the left side and once on the right side), and one operation for EHR before a resection of both first ribs finaly had a curative effect. Six patients presented with an incomplete resection of the first rib. Additional venous compression symptoms were seen in 14 limbs; symp-

toms of arterial compression were evident in 15 limbs (Figs. 1-3). A sudden onset of Paget Schroetter syndrome (n = 2) and distal emboliza- tions (n = 3) were the first symptoms in five patients. The duration of symptoms was up to 3 years in 11 patients and longer than 3 years in 10 patients. A bilaral manifestation was observed in 13 patients. During the preoperative examinations, chest radiography, neurophysi-

ological tests, Doppler sonography, and duplex ultrasound were done as a routine. CT, MRI, arteriography, and venography were performed when clinically indicated. Pre- and intraoperative findings revealed the cervical rib in seven patients,

B.S. Lutz et al.: Thoracic Outlet Syndrome, Vascular Compression

Table 1. Symptoms at initial presentation

No. of patients Symptom with symptom

Neurological 26 Venous 14 Arterial 15 Bilateral manifestation 13

Table 2. Number of operations (n = 29 in 15 patients) before diagnosis of TOS

Operations Operation (type) (number)

203

CTS right 3 CTS left 4 SUS right 6 SUS left 4 EHR 6 Incomplete resection of the

1st rib/transv, process 6

CTS: carpal tunnel syndrome; SUS: sulcus ulnaris compression syndrome; EHR: Epicondylitis humeri radialis.

Fig. 2. Arteriography of another young female patient showing the right subclavian artery while right arm is at rest.

Fig. 3. Same arteriography as Figure 2 showing the effect on the subcla- vian artery when the arm is elevated.

Fig. 1. Right subclavian artery during provocation test resulting in a ste- nosis of the artery in a young female patient.

bilateral in three of them. Frequently this was combined with a relative hypertrophy of the scaleni muscles. In nine patients, strong fibromuscular bands causing a compression to the brachial plexus and the vascular bundle were observed intraoperatively, in four cases bilaterally. A callus formation after the fracture of the clavicle was the reason for neurological TOS in two patients. As mentioned above, six patients showed an incomplete resection of the first rib with resisting symptoms. In two patients, no specific reason for TOS could be found (Table 3).

All patients underwent transaxillary/supraclavicular resection of the first rib using the transaxillar route in the first three cases only, bilaterally in seven. Additional resection of a cervical rib with the scaleni muscles was performed in seven patients, bilaterally in three. Resection of the first rib and neurolysis of the brachial plexus was done in two patients with callus formation after fracture of the clavicle (Table 4).

In the two patients with Paget Schroetter syndrome a thrombolytic therapy was performed primarily, followed by excision of the first rib 4-6 weeks later. Three patients with distal embolizations of several fingers required simultaneous thromboembolectomy and thrombolytic therapy be- fore they were referred to us for TOS surgery.

Six patients of 13 with bilateral symptoms of TOS were operated on unilaterally because of minor symptoms of the contralateral arm.

The follow-up time for this study was at least 10 months to 5 years after the operation. Investigations included clinical examination, Doppler so- nography of the peripheral and subclavian arteries and veins, and neuro-

Table 3. Factors in the development of TOS

Factor No. of limbs

Fracture of the clavicle 2 Cervical rib/hypertropy Mm. scaleni 10 Fibromuscular bands 13 Incomplete prior 1st rib resection 6 Unknown 2 Total 33

Table 4. Operations (33) for TOS

Resection of the 1st rib Resection of a cervical rib with the Mm. scaleni Neurolysis of the plexus brachialis + resection of Ist rib

33 a 7 2

~Bilateral operation 7.

logical electrodiagnostic tests. In specific cases, a phlebography was also performed.

R e s u l t s

In 14 l i m b s (n = no. o f l i m b s 15) w i t h ar te r ia l c o m p r e s s i o n , s u r g e r y s h o w e d a c u r a t i v e e f f e c t ( T a b l e 5). I n o n e p a t i e n t

204 B.S. Lutz et al.: Thoracic Outlet Syndrome, Vascular Compression

Table 5. Clinical outcome following surgery for TOS (33 limbs)

Symptoms Complete Partial (no. of limbs) relief relief

Neurological (33) 26 7 Weakness of the arm (1) 1 Arterial (15) 14 1 Venous (14) 6 8

with distal embolization a minor amputation of parts of his fingers had been necessary because of necrosis.

Out of a total of 14 limbs only six with venous symptoms were free of symptoms after surgery. The remaining eight limbs showed an improvement, however, the patients com- plained of a heaviness of the arm and a tendency to swell- ing. Neurological disorders, especially pain, were totally eliminated in 26 limbs though six patients still complained of slight diffuse pain in the operated arm, in one case bi- laterally. These statistics include the patient after minor am- putation of parts of his fingers following distal emboliza- tion, four patients with a remaining slight venous conges- tion in their arms, and one patient with a large callus after a fracture of the clavicle. This patient, who had undergone five operations on the fracture, suffered from a compression of the medial branch of the brachial plexus. Preoperatively an evident weakness of the arm was observed, but it showed an improvement postoperatively. However, an objective weakness in this arm was still obvious at our last examina- tion 1 year after surgery. All patients with symptoms of epicondylitis humeri radialis (n = 12) were free of symp- toms after surgery. Prior to the operation for TOS, six of them had had a denervation surgery at the radial epicondyle without achieving relief. There were no complications, i.e., no pneumo- or hemothorax, no bleeding, and no injury of any nerve after using the supraclavicular approach. In one early case where the transaxillary approach was used, a postoperative hemothorax required a revision.

Discussion

The thoracic outlet compression syndrome may be caused by a number of anatomic abnormalities in the upper thoracic apertura as well as by degenerative disorders or after trauma [2,4,6,28]. Symptoms are due to the compression of the brachial plexus and the subclavian artery and vein. Accurate diagnosis of TOS is difficult and there is considerable con- troversy over this topic [20,27]. Among those who accept the existence of TOS, how to treat it best is the question. Excellent results after physiotherapy have been reported [13-15]. Since severe injuries during surgery are described [16,17,20,25,26], physical therapy is recommended unless there is significant vascular compromise or motor loss [7,25]. In agreement with this, surgery was chosen by our group for cases of vascular compression and pathological findings in electroneurological tests, after having excluded other disorders.

In 1861, Coote [29] first described the resection of the processus transversalis C7 as an operative treatment for compression syndrome in the upper thoracic aperture. In

1910, Murphy [30] was the first to report results after re- section of the first rib in TOS using the supraclavicular route. The scalenotomy as standard treatment for TOS was initiated by Adson and Coffey [31] in 1927. But until 1966 when Roos [32] published excellent results after resection of the first rib, surgery for TOS had been unsatisfactory, especially in relieving neurological symptoms whereas Roos preferred the transaxillary approach. In 1962, Clagett [33] described the posterior subscapular approach for re- secting the first rib in TOS. We prefer the supraclavicular approach since it offers good vision, thus minimizing the risk of damage to the neurovascular bundle. The only com- plication that occurred in our group was a hemothorax after using the axillary route in one of the first three operations.

A resection of the first rib is always performed in specific cases, combined with additional procedures according to the intraoperative findings (Table 4). A scalenotomy or a neu- rolysis of the brachial plexus especially is more difficult using the axillary approach [2,23,34]. In the case of con- comitant reconstruction of the subclavian vessels, the infra- clavicular route or both incisions as described by Durham (12) offer an alternative approach to the affected structures.

Thompson and Webster [24], who prefer the transaxillar approach, strongly recommend a separate supraclavicular incision if the subclavian artery is to be reconstructed. Nei- ther an aneurysm of the subclavian artery [35] nor a "he- modynamic" aneurysm, as observed by Thompson and Webster, were seen in our patients. In the eight patients with venous compression who showed an improvement of their symptoms after surgery but still complained of a slight heaviness and swelling of the arm during work, a postop- erative phlebography showed patent veins. In those patients, fibrosis of the vein wall due to long compression time with Paget-Schrotter-syndrome in two limbs could be discussed. Since the patients were satisfied with the achieved results, no further investigations were done. Maybe an intravascular ultrasound, as reported by Chengelis et al. [12] could help to solve this problem.

All patients with compression syndromes of the median nerve in the carpal tunnel showed a definite improvement (clinically and in electroneurological tests) after surgery. Twelve patients with symptoms of lateral epicondylitis were free of symptoms after surgery. This success can be ex- plained by the anatomical findings of Wilhelm in 1962 [10] who noted that the lateral elbow region is innervated by the radial nerve only. This nerve may be irritated proximally at the level of the upper thoracic region in the case of TOS, resulting in symptoms of lateral epicondilitis. Wilhelm [36,37] also described a chronic edema due to a functional blockage of the subclavian vein as a predisposing factor for median nerve compression and painful tendovaginitis as one possible factor in the development of a reflexdystrophy in the arm.

In conclusion, conservative therapy for TOS is recom- mended if there is no evidence of vascular compression and/or specific pathological neurological findings, espe- cially in trauma cases [38]. In patients with evidence of vascular compression and pathological findings in electro- neurological tests, surgical treatment is regarded as the best therapy. Resection of the first rib [16,22-24,39,40], resec-

B.S. Lutz et al.: Thoracic Outlet Syndrome, Vascular Compression 205

tion of a cervical rib, scalenotomy, and neurolysis of the brachial plexus according to the intraoperative findings are recommended. Our experiences using the supraclavicular approach indicate that this is a safe route that permits good vision during surgery and excellent exposure of the com- pressed neurovascular structures [18,34,41]. Good results are achieved with minimal risk to the patient's health.

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