Thoracic outlet syndrome: a multidisciplinary problem with a perspective for microsurgical management without rib resection.
BACKGROUND
Thoracic outlet syndrome (TOS) refers to a group of complex symptoms in the upper extremity caused by compression of the brachial plexus, subclavian artery and vein. Different surgical approaches were described for the management of TOS. There is, however, no "gold standard" procedure for this complicated and multidisciplinary problem.


OBJECTIVE
This study evaluated the effectiveness of a microsurgical neurovascular decompression in the treatment of TOS.


METHODS
11 patients suffering from TOS (for 1.3 to 15 years after the beginning of the symptoms) were selected for a treatment of the complex symptoms of pain (diffuse or irradiated to the arm and hand), aching or paresthesia in the neck, shoulder, anterior chest, upper extremity and hand. Four of the 11 patients were suffering from signs of vascular compression. Eight patients showed slow progressive neurological deterioration (distribution of the ulnar nerve) with partial muscle atrophy. Patients underwent a microsurgical treatment using a supraclavicular approach followed by brachial plexus neurolysis, scalenectomy and release of the subclavian artery and vein without rib resection. Postoperative results were classified, using Am. J. Surg. (176: 215-218, 1998) scale (4), as good, fair and poor.


RESULTS
Surgical results were studied, with a follow-up of 24 to 48 months. Prior to surgery, all patients had partial or severe limitation in physical activities. Post-operative follow-up showed that 9 (82%) of the 11 patients returned to normal everyday physical activities with a complete or significant relief of the symptoms (good results). In 2 patients (18%) the pain decreased and the use of medication was reduced (fair results). Eight of the 11 patients returned to full or partial employment. There were no cases of poor results in the study.


CONCLUSIONS
Microsurgical neurovascular decompression of TOS without a removal of the cervical or first rib using a supraclavicular approach is an effective treatment method for a relief or complete release from symptoms and allows most patients to return to an active normal life.
Rochkind
S
S
Tel Aviv Sourasky Medical Center, Division of Peripheral Nerve Reconstruction, Tel Aviv University, Tel Aviv, Israel. rochkind@zahav.net.il
Shemesh
M
M
Patish
H
H
Graif
M
M
Segev
Y
Y
Salame
K
K
Shifrin
E
E
Alon
M
M
D000200:Action Potentials; D000293:Adolescent; D000328:Adult; D019299:Decompression, Surgical; D004651:Employment; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008866:Microsurgery; D009043:Motor Activity; D018482:Muscle, Skeletal / Q000503:physiopathology; D019635:Neurosurgical Procedures; D011182:Postoperative Care; D011184:Postoperative Period; D011446:Prospective Studies; D013901:Thoracic Outlet Syndrome / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures