Kendall Likes

A Decade of Excellent Outcomes after Surgical Intervention in 538 Patients with Thoracic Outlet Syndrome

BACKGROUND Our aim was to evaluate the outcomes of patients who underwent first rib resection (FRR) for all 3 forms of thoracic outlet syndrome (TOS) during a period of 10 years. STUDY DESIGN Patients treated with FRR from August 2003 through July 2013 were retrospectively reviewed using a prospectively maintained database. RESULTS Five hundred and thirty-eight patients underwent 594 FRRs for indications of neurogenic (n = 308 [52%]), venous (n = 261 [44%]), and arterial (n = 25 [4%]) TOS. Fifty-six (9.4%) patients had bilateral FRR. Fifty-two (8.8%) patients had cervical ribs. Three hundred and ninety-eight (67%) FRRs were performed on female patients, with a mean age of 33 years (range 10 to 71 years). Three hundred and forty (57%) were right-sided procedures. Seventy-five children (aged 18 years or younger) underwent FRRs; 25 during the first 5 years and 50 during the second 5 years. When comparing the second 5-year period with the first 5-year period, more patients had venous TOS (48% vs 37%; p < 0.02); fewer patients had neurogenic TOS (48% vs 58%; p < 0.05), and improved or fully resolved symptoms increased from 93% to 96%. Complications included 2 vein injuries, 2 hemothoraces, 4 hematomas, 138 pneumothoraces (23%), and 8 (1.3%) wound infections. Mean length of stay was 1 day. CONCLUSIONS Excellent results were seen in this surgical series of neurogenic, venous, and arterial TOS due to appropriate selection of neurogenic patients, use of a standard protocol for venous patients, and expedient intervention in arterial patients. There is an increasing role for surgical intervention in children.

The significance of cervical ribs in thoracic outlet syndrome

OBJECTIVE The purpose of this study was to review our operative experience in patients with thoracic outlet syndrome (TOS) resulting from cervical ribs causing clinical symptoms. METHODS This study is a retrospective review of a prospectively acquired database of patients with TOS treated with first rib resection and scalenectomy with or without cervical rib resection at the Johns Hopkins Medical Institutions. RESULTS Between October 2003 and June 2011, a total of 23 cervical rib resections were performed on 20 patients, three of whom had bilateral cervical ribs resected during separate operations. Seven patients presented with subclavian artery thrombosis. Three of seven patients had subclavian artery aneurysms and underwent cervical rib resection through a supraclavicular approach to facilitate subclavian artery bypass. Five patients presented with an ischemic upper extremity without thrombosis and underwent transaxillary first rib and cervical rib resection. Three patients presented with subclavian vein thrombosis; two of the three patients underwent balloon dilation 2 weeks postoperatively for stenosis. Additionally, five patients presented with neurogenic TOS evidenced by pain, numbness, and weakness without vascular compromise in the affected arm. Cervical ribs with bony fusion to the first rib were found in 17 of 23 cases (74%). CONCLUSIONS Cervical ribs causing clinical symptoms are large and frequently fused to the first rib, and can result in aneurysm formation or thrombosis. In our experience, both the cervical rib and the first rib must be removed to relieve arterial compression and can usually be done through a transaxillary approach. Only patients with aneurysms needing arterial reconstruction require resection of the artery from a supraclavicular approach.

Impact of anterior scalene lidocaine blocks on predicting surgical success in older patients with neurogenic thoracic outlet syndrome

OBJECTIVE Surgical management of neurogenic thoracic outlet syndrome (NTOS) is controversial due to the lack of predictors of success and difficulties in patient selection. We sought to examine the effects of patient demographics, etiology, duration of symptoms, and the selective use of lidocaine and botulinum toxin anterior scalene blocks on outcomes of patients undergoing transaxillary decompression with first rib resection and scalenotomy for NTOS. METHODS Patients with NTOS who had failed physical therapy and had transaxillary decompression between 2003 and 2009 were reviewed retrospectively from a prospectively maintained database. Patients were stratified to age groups < 40 and ≥ 40 years old. Bivariate and multivariate statistical models of analysis were used. RESULTS One hundred fifty-nine procedures (16 patients bilateral; three patients with cervical ribs; 84.3% women; median age, 37 years; range, 21-64 years) were identified. Ninety-six patients were < 40 and 63 were ≥ 40 years old. Etiology was similar in both groups: trauma 43% vs 46% and chronic repetitive motion 57% vs 54%. Duration of symptoms was less in the <40 group (38.4 vs 66 months; P < .05). More patients in the ≥ 40 group had other spine, shoulder, or arm operations (38% vs 18%; P < .05). Median follow-up for the cohort was 12 months. Transaxillary decompression was more likely to relieve symptoms in patients <40 vs ≥ 40 years old (90% vs 78%; P < .05). Lidocaine blocks were positive in 89% (49 of 55 patients) in the <40 group and 93% (43 of 46 patients) in the ≥ 40 group. After adjusting for patient presenting factors in multivariate analysis, the impact of a successful lidocaine block in patients ≥ 40 years old was greater than in patients < 40 years old (improvement of surgical success of 14% in the > 40 group vs 7% in the < 40 group; P = .05). Botulinum toxin blocks were successful in less patients, 38% (eight of 21 patients) in the < 40 group and 52% (12 of 23 patients) in the ≥ 40 group but were not predictive of symptom relief after transaxillary decompression. CONCLUSIONS Although patients with NTOS < 40 years old achieve more symptom relief overall after transaxillary decompression as compared to patients ≥ 40 years old, the selective use of lidocaine blocks is more beneficial in predicting surgical success in patients ≥ 40 years old given that younger patients < 40 years old seem to do well regardless.

Routine Venography Following Transaxillary First Rib Resection and Scalenectomy (FRRS) for Chronic Subclavian Vein Thrombosis Ensures Excellent Outcomes and Vein Patency

To assess the role of postoperative venography in patients treated with first rib resection and scalenectomy (FRRS) for effort thrombosis, a retrospective review was done to evaluate long-term venous patency in 84 patients treated at the Johns Hopkins Medical Institutions. Patients undergo venography 2 weeks postoperatively. If there is >50% stenosis, the subclavian vein is dilated and the patient receives anticoagulation. If the vein is occluded, patients are maintained on anticoagulation. Of the 85 patients, 21 patients had patent veins, 47 patients had stenotic veins, and 16 patients had chronically occluded veins. In follow-up, symptomatic restenosis was seen in 3 patients and those veins were redilated. Two other patients had late occlusions at 23 and 63 months and received anticoagulation and redilatation, respectively. Using venography to guide postoperative management, 79 of 84 patients had patent veins many years postoperatively. Long-term patency, as seen by duplex scan, was achieved in nearly all patients using this protocol.

Management of unresolved, recurrent, and/or contralateral neurogenic symptoms in patients following first rib resection and scalenectomy

BACKGROUND Surgical treatment for neurogenic thoracic outlet syndrome does not always yield successful outcomes. The purpose of this study was to describe patients with unresolved, recurrent, and/or contralateral symptoms following first rib resection and scalenectomy (FRRS) and to determine therapies for improving their outcomes. METHODS Data on 161 neurogenic thoracic outlet syndrome patients (182 FRRS procedures) were prospectively collected from 2003 to 2011 and retrospectively reviewed for evidence of unresolved, recurrent, and/or contralateral neurogenic symptoms following FRRS. Demographic and clinical characteristics, interventions, and outcomes were compared between these patients and those with a successful result. RESULTS Twenty-three patients (24 FRRS) had unresolved symptoms at a mean of 16.1 ± 14.7 postoperative months. Compared with successes, these patients were older (mean age, 45 vs 38 years; P = .002) and active smokers (33% vs 13%; P = .031), with a longer duration of symptoms (90 vs 48 months; P = .005). They had higher rates of chronic pain syndromes (67% vs 14%; P < .001), neck and/or shoulder comorbidities (58% vs 22%; P < .001), preoperative opioid use (67% vs 31%; P = .001), and preoperative Botox injections (46% vs 20%; P = .009) with less relief (18% vs 64%; P = .014). Sixteen patients had recurrent symptoms at a mean of 12.1 ± 9.7 postoperative months. These patients had more chronic pain syndromes (38%; P = .028) and neck and/or shoulder comorbidities (50%; P = .027), with recurrence secondary to scar tissue (69%; P < .001) and reinjury (31%; P = .002). Postoperative treatments for both groups included physical therapy and local injections, where six unresolved (26%) and 13 recurrent (81%) patients achieved freedom from opioids at the end of the follow-up period. Twenty-one patients had contralateral symptoms and underwent secondary FRRS at a mean of 15.0 months (range, 7-30 months) following primary FRRS. The first operation was successful in 90% of cases. CONCLUSIONS Patients with unresolved symptoms are older, active smokers with more comorbid pain syndromes, neck and/or shoulder disease, and a longer symptom duration. These patients face a more difficult recovery, whereas patients with recurrent symptoms are well managed with physical therapy and Botox injections. Patients with contralateral symptoms at >1 year are effectively treated with secondary FRRS. Patients must be followed closely after FRRS to determine if additional interventions are necessary to ensure successful results.

Lessons Learned in the Surgical Treatment of Neurogenic Thoracic Outlet Syndrome Over 10 Years

Objective: To evaluate our extensive experience over a decade in the treatment of patients with neurogenic thoracic outlet syndrome (NTOS) who underwent first rib resection and scalenectomy (FRRS). Methods: Patients treated with FRRS for NTOS from 2003 to 2013 were retrospectively reviewed using a prospectively maintained database. Results: Over 10 years, 286 patients underwent 308 FRRS. During the first 5-year period, 127 FRRS were performed (96 F, 31 M), with an average age of 36.9 years. During the second 5-year period, 181 FRRS were performed (143 F, 38 M), with an average age of 33 years. A total of 24 children (age ≤18years) underwent FRRS, 9 during the first 5 years and 15 during the second 5 years. When comparing the second 5-year period to the first 5-year period, patients were younger (P = .066), reported a significantly shorter length of preoperative symptoms (35.4 vs 52.1 months, P < .01), prior narcotic use decreased from 31.5% to 23.8% (P < .05), and a history of prior surgical intervention on the ipsilateral side (head, neck, and shoulder) increased from 30.1% to 51.9% (P < .01). Use of lidocaine blocks as a diagnostic tool (57%-35.4%, P = .06) and Botox blocks as a therapeutic tool (29.1%-12.7%, P < .01) decreased in the second 5 years with similar positive results. Improved or fully resolved symptoms following FRRS increased from 89% in the first 5 years to 92.8% in the second 5 years. Average length of follow-up over the 10-year period was 13.4 months. Conclusion: Excellent results were seen in this surgical series reported for NTOS. Younger patients with shorter duration of symptoms with less narcotic use led to even better FRRS results in the second 5 years of surgical intervention. An established vascular practice for referrals for NTOS resulted in an increased number of appropriate patients for surgical intervention, requiring fewer lidocaine and/or Botox injections preoperatively.

Remaining or Residual First Ribs Are the Cause of Recurrent Thoracic Outlet Syndrome

BACKGROUND Surgical intervention for neurogenic thoracic outlet syndrome (NTOS) is not always successful. Treatment plans can be difficult in patients presenting with recurrent symptoms. The purpose of this study was to evaluate outcomes of this patient subset, who underwent operative intervention to remove a remaining or residual first rib because of recurrent thoracic outlet syndrome (TOS)-related symptoms. METHODS Data on 15 patients who presented with previous scalenectomy, brachial plexus lysis, or first rib resection and scalenectomy (FRRS) with residual rib present on chest radiograph from 2004 to 2012 were retrospectively reviewed from a prospectively maintained database, with approval from the Institutional Review Board of Johns Hopkins Hospital. Patients were classified as having a remaining first rib if they presented with recurrent NTOS symptoms, had previously undergone scalenectomy and/or brachial plexus lysis alone to decompress the thoracic outlet, and exhibited an intact first rib on chest X-ray, whereas patients were classified as having a remnant rib if they presented with recurrent symptoms of NTOS, had previously undergone a first rib resection at another institution, and exhibited an anterior or posterior first rib on chest X-ray. Demographic and clinical characteristics along with postoperative outcomes were evaluated. RESULTS Different precipitating events reaggravated symptoms in 12 patients. Events included car accidents (n = 4), work-related repetitive movements (n = 5), lifting heavy objects (n = 2), and repetitive injury (n = 1). Group 1: Previous scalenectomy (n = 2), brachial plexus lysis alone (n = 2), or both (n = 3). Seven patients (2 men and 5 women; mean age 34 [25-53]) presented with NTOS symptoms due to a remaining first rib at an average of 24 months (range: 2-68) after their initial operation at another institution. All underwent transaxillary first rib resection, residual scalene resection, and lysis of scar tissue. Perioperative complications included 3 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 17 months (range: 1-79), and all the patients improved in the postoperative period. Group 2: Residual rib (n = 8). Eight patients (2 men and 6 women; mean age 39 [24-58]) presented with a residual first rib at an average of 44 months (range: 12-107) after their initial operation at another institution. Six patients had undergone prior supraclavicular FRRS, 1 had undergone previous transaxillary FRRS, and 1 had undergone FRRS via an anterior chest approach. Of the 8 patients, 7 presented with neurogenic symptoms alone, and 1 presented with recurrent venous thrombosis in addition. A residual rib was present in all the 8 patients, as seen by a chest radiograph. A transaxillary approach was used to resect the residual first rib, anterior scalene muscle remnant, and scar tissue in 7 patients, and a supraclavicular approach was used in 1 patient. Perioperative complications included 4 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 13 months (range: 1-64), and all the patients improved in the postoperative period. CONCLUSIONS Patients who present with recurrent symptoms of TOS need to be evaluated for remaining or residual first ribs. Operative intervention to remove the remaining or residual first rib in this patient subset is beneficial and can be performed without significant morbidity. Patients undergoing procedures for TOS support our procedure of complete first rib removal at the time of the initial operation to prevent recurrence of symptoms.

Preoperative Duplex Scanning is a Helpful Diagnostic Tool in Neurogenic Thoracic Outlet Syndrome

Objective: To evaluate the diagnostic role of venous and arterial duplex scanning in neurogenic thoracic outlet syndrome (NTOS). Methods: Retrospective review of patients who underwent duplex ultrasonography prior to first rib resection and scalenectomy (FRRS) for NTOS from 2005 to 2013. Abnormal scans included ipsilateral compression (IC) with abduction of the symptomatic extremity (>50% change in subclavian vessel flow), contralateral (asymptomatic side) compression (CC) or bilateral compression (BC). Results: A total of 143 patients (76% female, average age 34, range 13-59) underwent bilateral preoperative duplex scanning. Ipsilateral compression was seen in 44 (31%), CC in 12 (8%), and BC in 14 (10%). Seventy-three (51%) patients demonstrated no compression. Patients with IC more often experienced intraoperative pneumothoraces (49% vs. 25%, P < .05) and had positive Adson tests (86% vs. 61%, P < .02). Conclusion: Compression of the subclavian vein or artery on duplex ultrasonography can assist in NTOS diagnosis. Ipsilateral compression on abduction often correlates with Adson testing.

Females With Subclavian Vein Thrombosis May Have an Increased Risk of Hypercoagulability

BACKGROUND Subclavian vein thrombosis (SVT) is usually caused by vigorous activity or extensive use of the upper extremity. Patients are tested for hypercoagulability if they present with a spontaneous clot unassociated with such activity. The objective of this study was to determine the prevalence of hypercoagulability in patients undergoing first rib resection and scalenectomy presenting with SVT. METHODS Using a prospectively maintained database from August 2003 through June 2011, patients were retrospectively reviewed for hypercoagulability testing and clinical outcomes. RESULTS One hundred forty-three patients (79 females and 64 males; mean [range] age, 32 [16-71] years) presented with SVT, of whom 55 patients (43 females and 12 males; mean age, 32 [16-61] years) had undergone hypercoagulable testing. Fourteen patients (25.5%) (12 females and 2 males; mean age, 27 [16-46] years) had an abnormal hypercoagulable profile. A factor V Leiden mutation was present in 6 patients, protein S deficiency in 4, a plasminogen-activator inhibitor-1 (PAI-1) deficiency in 2, and 1 patient each with protein C deficiency, anticardiolipin antibodies, factor VII mutation, factor II mutation, and antiphospholipid antibodies. Immediate and long-term postoperative vein patency was similar to patients without hypercoagulability. Patients were placed on lifelong anticoagulation therapy if they had a PAI-1, protein C, or protein S deficiency. CONCLUSIONS Patients with hypercoagulability do as well with first rib resection and scalenectomy for SVT as those without hypercoagulability. In our patient subset, more females were tested owing to a history of spontaneous thrombosis and an increased incidence of hypercoagulable disorders. Because of our findings, we believe younger women with SVT should undergo hypercoagulable testing to identify the need for long-term anticoagulation therapy.

McCleery Syndrome: Etiology and Outcome

Objectives: Patients presenting with swelling of the upper extremity without thrombosis have McCleery syndrome or intermittent compression of the subclavian vein. The purpose of this study was to determine outcomes in these patients who underwent first rib resection and scalenectomy (FRRS). Methods: Using a prospectively maintained database from 2003 to 2011, patients were retrospectively reviewed for presentation, diagnosis, treatment, and clinical outcomes. Results: Of the patients presenting with venous thoracic outlet syndrome, 19 (11%; 13 F/6 M; mean age 26 [10-44]) presented with intermittent arm swelling, of which 3 were identified as having chronic thrombus. A total of 20 FRRS operations were performed. Conclusions: First rib resection and scalenectomy is effective in relieving symptoms in patients with McCleery syndrome. These patients do not generally need a postoperative venogram unless they experience continuing symptoms. In patients with chronic thrombus, routine postoperative venography at 2 weeks is indicated. Patients can present with intermittent compression if an acute episode of deep vein thrombosis is not aggressively treated.