A New Neurovascular Lysis For Thoracic Outlet Syndrome: A Follow Up Study

The term TOS is used to describe patients with compression of the subclavian vein, subclavian artery, and the brachial plexus in the region of the thoracic outlet. The wide variability of patient symptoms that include vascular and/or neural signs, diffuse symptoms, and the lack of a valid reliable test to confirm the diagnosis of TOS makes it difficult to identify correctly those patients with TOS. There are few topics more controversial in the field of surgery than TOS after first maned by Peet in 1956. This clinical picture has also been named as costoclavisular syndrome, cervical rib syndrome, scalenius anticus syndrome, subclavius tendon syndrome or pectoralis minor syndrome by various authors.It was early in 1907 that keen reviewed 42 cases of cervical rib excision with TOS symptoms from the literature. For more than 100 years various surgical treatments for TOS have been tried. The first case report of removal of the first rib for thoracic outlet symptoms was published with a 3-month follow-up by Murphy in 1910. In 1927, Adson and Coffey suggested the division of the scalenus anticus muscle to relieve symptoms in patients with TOS symptoms. And they published the "classic" article on cervical rib syndrome, which described 31 patients who underwent rib resection and 5 patients who underwent only an anterior scalenotomy, which was performed to avoid the "frequent complications of rib resection." In 1962, Clagett introduced resection of the first rib as the optimal operation rather than scalenotomy for scalenus anticus syndrome.In the same year, Falconer and Li noted good relief of symptoms in 12 of 13 cases using a supraclavicular first rib resection approach. In 1966, Roos described the transaxillary technique of first rib resection in 12 patients. Since then, the first rib resection has become the mainstream treatment of TOS.There is no denying that the first rib resection play an important role in the treatment of TOS, it can release both the scalene triangle and the costoclavicular space in one incision, but the not released subcoracoid space together with the scar formed by retracted scalene muscles made a degree of recurrence and the technique has a larger side injury in operation. Therefore, to research a less invasive and more effective surgery technique had been one of the hottest topic for all the clinicians at home and abroad. The new method we took can fully release all the compression factors on the plexus and subclavical vessels from intervertebral foramina to the axillary in order to get more positive effects.Objective:To assess the outcome of the new surgery treatment for thoracic outlet syndrome(TOS) in our department.Methods:Retrospectively analysis of 5 cases 10 extremities (male,3; female, n=2) of TOS was done by review. All these cases were treated by our new neurovascular lysis. Postoperative followed-up by comparing preoperative and postoperative clinical symptoms, physical examination, electrophysiological testing results and used the postoperative functional evaluation criteria assess by Roos and the Disabilities of Arm, Shoulder, and Hand(DASH) questionnaire to evaluate the efficacy of the surgical technique and to analyze the reasonableness of the surgical advantages and disadvantages.Result:All cases were followed up between 5 months to 49 months. All of the 10 extremities had great alleviated in pain, paresthesia, muscle weakness and muscle atrophy, electrophysiological improvement compared with preoperative results. According to the postoperative functional evaluation criteria assess by Roos:excellent 7 extremities, good 3 extremities, medium 0 extremity, poor 0 extremity and the mean DASH score improved from 53 before surgery to 19 after surgery.We had seen the brachial plexus left from the intervertebral foramen to the left pectoralis minor muscle gap and into the upper arm, existing multi-site compressions.Conclusion:1. Brachial plexus in thoracic outlet had multiple compression sites, only release one site can relief the symptoms, but the long-time effect was not very reliable and it had become a cause of postoperative recurrence.2. We used supraclavicular- subclavicular union approach to fully lysis brachial plexus, remaining the first rib. After short-term follow-up we obtain good results,if there will be also good rusults in long terms follow-up,we can provides a less invasive and more effective surgery treatment for TOS.