This study was conducted in accordance with Declaration of Helsinki and local clinical ethics committee (2018/09).
1. Physical Examination
NOTE: The provocative tests for diagnosis of the TOS are depicted in Figure 1.
<ol>
	<li>For the Adson test (scalene test, Figure 1A), bring the patient&#8217;s shoulder to external rotation with slight abduction and a little bit of extension and palpate the radial pul...

<ol>
	<li>Peet, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+evaluation+of+a+therapeutic+exercise+program.">Thoracic outlet syndrome: evaluation of a therapeutic exercise program.</a> InProc Mayo Clinic. 31, 281-287 (1956).</li><li>Han, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+approach+in+thoracic+outlet+syndrome:+the+importance+of+resection+of+the+first-rib.">Transaxillary approach in thoracic outlet syndrome: the importance of resection of the first-rib.</a> European Journal of Cardio-Thoracic Surgery. 24 (3), 428-433 (2003).</li><li>Yavuzer, &. #. 3. 5. 0. ;., Atinkaya, C., Tokat, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+predictors+of+surgical+outcome+in+patients+with+thoracic+outlet+syndrome+operated+on+via+transaxillary+approach.">Clinical predictors of surgical outcome in patients with thoracic outlet syndrome operated on via transaxillary approach.</a> European Journal of Cardio-Thoracic Surgery. 25 (2), 173-178 (2004).</li><li>Roos, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+approach+for+first+rib+resection+to+relieve+thoracic+outlet+syndrome.">Transaxillary approach for first rib resection to relieve thoracic outlet syndrome.</a> Annals of Surgery. 163 (3), 354 (1966).</li><li>Jubbal, K. T., Zavlin, D., Harris, J. D., Liberman, S. R., Echo, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Morbidity+of+First+Rib+Resection+in+the+Surgical+Repair+of+Thoracic+Outlet+Syndrome.">Morbidity of First Rib Resection in the Surgical Repair of Thoracic Outlet Syndrome.</a> Hand. , 1558944718760037 (2018).</li><li>Likes, K. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lessons+learned+in+the+surgical+treatment+of+neurogenic+thoracic+outlet+syndrome+over+10+years.">Lessons learned in the surgical treatment of neurogenic thoracic outlet syndrome over 10 years.</a> Vascular and Endovascular Surgery. 49 (1-2), 8-11 (2015).</li><li>Akku&#351;, M., Ya&#287;murlu, K., &#214;zarslan, M., Kalani, M. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+outcomes+of+neurogenic+thoracic+outlet+syndrome+based+on+electrodiagnostic+tests+and+QuickDASH+scores.">Surgical outcomes of neurogenic thoracic outlet syndrome based on electrodiagnostic tests and QuickDASH scores.</a> Journal of Clinical Neuroscience. 58, 75-78 (2018).</li><li>Peek, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome.">Long-term functional outcome of surgical treatment for thoracic outlet syndrome.</a> Diagnostics. 8 (1), 7 (2018).</li><li>Sanders, R. J., Annest, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technique+of+supraclavicular+decompression+for+neurogenic+thoracic+outlet+syndrome.">Technique of supraclavicular decompression for neurogenic thoracic outlet syndrome.</a> Journal of Vascular Surgery. 61 (3), 821-825 (2015).</li><li>Sanders, R. J., Hammond, S. L., Rao, N. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+a+review.">Thoracic outlet syndrome: a review.</a> The Neurologist. 14 (6), 365-373 (2008).</li><li>Vos, C. G., &#220;nl&#252;, &. #. 1. 9. 9. ;., Vo&#251;te, M. T., van de Mortel, R. H., de Vries, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+outlet+syndrome:+First+rib+resection.">Thoracic outlet syndrome: First rib resection.</a> Shanghai Chest. 1 (1), (2017).</li><li>Desai, S. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcomes+of+surgical+paraclavicular+thoracic+outlet+decompression.">Outcomes of surgical paraclavicular thoracic outlet decompression.</a> Annals of vascular surgery. 28 (2), 457-464 (2014).</li><li>Peek, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+functional+outcome+of+surgical+treatment+for+thoracic+outlet+syndrome.">Long-term functional outcome of surgical treatment for thoracic outlet syndrome.</a> Diagnostics. 8 (1), 7 (2018).</li><li>Urschel, H. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transaxillary+first+rib+resection+for+thoracic+outlet+syndrome.">Transaxillary first rib resection for thoracic outlet syndrome.</a> Operative Techniques in Thoracic and Cardiovascular Surgery. 10 (4), 313-317 (2005).</li><li>Sheth, R. N., Campbell, J. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+thoracic+outlet+syndrome:+a+randomized+trial+comparing+two+operations.">Surgical treatment of thoracic outlet syndrome: a randomized trial comparing two operations.</a> Journal of Neurosurgery: Spine. 3 (5), 355-363 (2005).</li><li>Urschel, H. C., Razzuk, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Neurovascular+compression+in+the+thoracic+outlet:+changing+management+over+50+years.">Neurovascular compression in the thoracic outlet: changing management over 50 years.</a> Annals of Surgery. 228 (4), 609 (1998).</li><li>Povlsen, B., Hansson, T., Povlsen, S. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+for+thoracic+outlet+syndrome.">Treatment for thoracic outlet syndrome.</a> Cochrane Database of Systematic Reviews. 11, (2014).</li><li>George, R. S., Milton, R., Chaudhuri, N., Kefaloyannis, E., Papagiannopoulos, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Totally+endoscopic+(VATS)+first+rib+resection+for+thoracic+outlet+syndrome.">Totally endoscopic (VATS) first rib resection for thoracic outlet syndrome.</a> The Annals of Thoracic Surgery. 103 (1), 241-245 (2017).</li><li>Strother, E., Margolis, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+first+rib+resection.">Robotic first rib resection.</a> Operative Techniques in Thoracic and Cardiovascular Surgery. 20 (2), 176-188 (2015).</li></ol>

TFRR is the most used surgical technique for treatment of TOS9,10,11. The advantage of the TFRR is that it provides a better cosmetic result with a hidden incision in the axilla without requirement of cutting the muscles to reach the surgical field. Its disadvantage is the relatively narrow and deep working space. The supraclavicular approach, which is preferred for arterial TOS treatment, puts the subclavian artery at less risk...

The compression of the brachial plexus, subclavian artery or vein in the scalene triangle is clinically known as thoracic outlet syndrome (TOS), first described by Peet et al.1. Thoracic outlet syndrome is subdivided into neurogenic (NTOS), arterial TOS, and venous TOS based on the underlying etiology1. Patients with NTOS (93-95% of TOS cases) present with pain, numbness, and ipsilateral weakness. Patients with venous TOS (3-5%) present with venous thrombosis, and patients with arterial TOS (1-2%) present with arterial thromboembolic event and ischemia. Conservative management of TOS includes medications and physiotherapy and is the first choice for TOS cases. The surgical treatment modalities include decompression procedures and are performed after conservative management has failed2. Decompression techniques include the transaxillary first rib resection (TFRR), supraclavicular first rib resection scalenectomy (SFRRS), scalenectomy (without first rib resection via supraclavicular or transaxillary), and posterior approach first rib resection (PA-FRR)3. The transaxillary first rib resection, a technique described by Roos et al. in 1966, is an effective method for treatment of TOS4,5. The main goal of TFRR is to completely remove the last cervical and first thoracic ribs and to decompress the underlying neurovascular bundle.
Vascular TOS (VTOS) are diagnosed with CT angiography, color duplex USG, and arteriography or venography, whereas the NTOS is diagnosed with X-ray, electrodiagnostic studies (needle electromyelography), color duplex Doppler USG, and cervical MRI. Physiotherapist and psychiatrist consultations should be obtained to exclude other disorders preoperatively.The symptom relief with lidocaine injection to the anterior scalene muscle is also a good indicator for diagnosis and predictor of surgical benefit in NTOS patients6.

<table>
	<tbody>
		<tr>
			<td>Ag Debakey vascular forceps 24 cm, 3.5 mm</td>
			<td>Lawton medizintechnik</td>
			<td>30-0032</td>
			<td>Check the hemorrhage</td>
		</tr>
		<tr>
			<td>Bone chisels curved 13x9.1/2&#39;&#39;</td>
			<td>Aesculap Inc.</td>
			<td>MB-992R</td>
			<td>Dissect the periost of the first rib</td>
		</tr>
		<tr>
			<td>Doyen-stille retractor 24 cm</td>
			<td>Lawton medizintechnik</td>
			<td>20-0650</td>
			<td>Skin- muscle retraction</td>
		</tr>
		<tr>
			<td>Foerster sponge forceps straight</td>
			<td>Lawton medizintechnik</td>
			<td>07-0156</td>
			<td>For swabbing</td>
		</tr>
		<tr>
			<td>Luer stille bone rongeur curved 27 cm</td>
			<td>Lawton medizintechnik</td>
			<td>38-0703</td>
			<td>Bone punches</td>
		</tr>
		<tr>
			<td>Luer stille rongeur straight 22 cm</td>
			<td>Lawton medizintechnik</td>
			<td>38-0400</td>
			<td>Rib cutter</td>
		</tr>
		<tr>
			<td>Mayo hegar needle holder 20.5 cm</td>
			<td>Lawton medizintechnik</td>
			<td>08-0184</td>
			<td>Suturing</td>
		</tr>
		<tr>
			<td>Metzenbaum scissors curved delicate 23 cm</td>
			<td>Lawton medizintechnik</td>
			<td>05-0665</td>
			<td>Dissection</td>
		</tr>
		<tr>
			<td>Overholt curved forceps delicate 30.5 cm</td>
			<td>Lawton medizintechnik</td>
			<td>06-0807</td>
			<td>Split the scalen muscles from the rib</td>
		</tr>
		<tr>
			<td>Roberts art forceps straight 24 cm</td>
			<td>Lawton medizintechnik</td>
			<td>06-0370</td>
			<td>For sponge and remove remain bone</td>
		</tr>
		<tr>
			<td>Roux retractor medium size 15.5 cm</td>
			<td>Lawton medizintechnik</td>
			<td>20-0402</td>
			<td>Wound retraction</td>
		</tr>
		<tr>
			<td>Semb rasparotry 22,5 cm, 12mm</td>
			<td>Lawton medizintechnik</td>
			<td>39-0252</td>
			<td>Dissect the muscle of the first rib</td>
		</tr>
		<tr>
			<td>Smith peterson model curved osteotome 13x205 mm</td>
			<td>Lawton medizintechnik</td>
			<td>46-0783</td>
			<td>Dissect the muscle of the first rib</td>
		</tr>
		<tr>
			<td>Stille -giertz rib shears 27 cm</td>
			<td>Lawton medizintechnik</td>
			<td>38-0200</td>
			<td>First rib cutting</td>
		</tr>
		<tr>
			<td>Stille osteotome 8x205 mm</td>
			<td>Lawton medizintechnik</td>
			<td>46-0248</td>
			<td>Dissect the periost of the first rib</td>
		</tr>
		<tr>
			<td>Wagner rongeur 5.5x210 mm</td>
			<td>Lawton medizintechnik</td>
			<td>53-0703</td>
			<td>Punches</td>
		</tr>
	</tbody>
</table>

transaxillary first rib resection for treatment of the thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol has been used for the decompression of trapped neurovascular structures in the TOS. Among the other surgical procedures, the advantage of the TFRR is that it has the smallest rate of recurrence and better cosmetic outcomes. The disadvantage of TFRR is that it provides a narrow, and deep working corridor that makes obtaining vascular control challenging.

Clinical Outcomes 
A total of 15 patients were included in this study. Three patients (20%) were male and 12 of patients (80%) were female. The mean age of patients was 30.6 &#177; 8.98 years. All male participants and 5 of female participants were manual laborers. The most common complaint of the NTOS group was arm-forearm pain and numbness weakness of grip and hypothenar atrophy. In the postoperative clinical follow-up, patients were questioned about their paresthesia and pain severity, overall sa...

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Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Here, we present a protocol of the transaxillary resection of the first rib for treatment of thoracic outlet syndrome caused by compression of the brachial plexus, subclavian vein and artery.

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol ...

This transaxillary first rib resection procedure can be used for the treatment of thoracic outlet syndrome caused by compression of brachial plexus, subclavian vein, and artery. The advantage of transaxillary first rib resection is that it has a smaller rate of recurrence and better cosmetic outcomes than standard treatment options. To perform an Adson test, bring the patient's shoulder to external rotation with slight abduction and a little bit of extension, and palpate the radial pulse.Extend the patient's head backward and rotate the head toward the tested shoulder. Ask the patient to breathe in and hold their breath. The test is considered positive when the reproduction of symptoms or the abolition of the radial pulse occurs and the symptoms resolve with rotation of the head to the contralateral side.For a costoclavicular brace test, bring the patient's arm to the back and depress and retract the arm over the patient's ipsilateral scapula. Check the radial pulse. If the pulse disappears or symptoms are reproduced, the test is considered positive.For the hyperabduction test, slightly extend the patient's arm and palpate the radial artery while abducting the arm 90 to 180 degrees. A positive test is indicated by a decrease in the pulse of the radial artery from baseline to the new position. For a Roos test, with the patient in either a sitting or standing position, move the patient's shoulders to 90-degree abduction and externally rotate and flex the elbows to 90 degrees.With the elbows slightly behind the frontal plane, have the patient open and close their hands for three minutes. The test is considered positive if the patient experiences heaviness, ischemic pain or weakness of the arms, or numbness and tingling of the hands. Discoloration of the hands is also meaningful for the test.For evaluation of the clinical improvement with surgical treatment, record the clinical findings from the physical examination and the QuickDASH questionnaire related to the symptoms of daily activities and social and psychological preoperative periods. To determine the preoperative electromyography values, use an appropriate commercial measuring system to measure the compound motor action potential, sensory nerve action potential, nerve conduction velocity, and F-wave latency according to standard protocols. For transaxillary first rib resection after confirming sedation, place the patient in the lateral decubitus position and wrap and elevate the arm in a 90-degree abduction position.Use a 10%sterile povidone-iodine solution for topical sterilization and drape the arm, axilla, and chest. Use sterile sheets on the rest of the body to prevent contamination. Make a five to seven-centimeter transverse incision below the axillary hairline, extending from the pectorals muscle anteriorly and the latissimus dorsi muscle posteriorly, and cross the skin's subcutaneous tissue and fascia to reach the anterior chest wall.With the aid of a focus scope, use blunt dissection to access the first rib and to pierce the overlying fascia. Dissect the pariosteal overlying the superior part of the rib and use monopolar cautery and rib raspatory to bluntly dissect the inferior edge of the rib from the surrounding muscles. Split the intercostal muscles until the costoclavicular ligament is at the sternocostal junction and the angular costa in the posterior costovertebral junction.In the superior edge of the first rib, expose the anterior scaling muscle anteriorly and the medial scalene muscle posteriorly. Place the curved forceps under the anterior and middle scalene muscle to cut the muscles at the level of their insertion over the first rib at the point farthest from the neurovascular bundle. Starting the resection of the first rib at the sternocostal junction anteriorly, turn a rib cutter blade from its superior edge into the inferior edge to resect the junction from the sternum, taking care that the neurovascular structures are preserved.To complete the resection, resect the posterior portion of the rib and disarticulate the region distal to the angle of the rib. After totally freeing the cervical rib from the surrounding tissue, resect and disarticulate the rib until the articular surface of the transverse process can be observed. After the procedure, perform a chest X-ray to rule out complications, such as pneumothorax.In uneventful cases, remove the thorax drain on postoperative day one. In the early postoperative period, examine movement of the arm and the treated side, and advise the patient to not perform any exhausting activity with the treated side. In this representative analysis, the most common complaint of the neurogenic thoracic outlet syndrome group was arm/forearm pain, numbness, and weakness of grip, and hypothenar atrophy.Electrodiagnostic outcomes and electromyography values were evaluated preoperatively and in the postoperative period is demonstrated, and a remarkable clinical improvement between pre-op and postoperative EMG values was observed. Take care to insert the curved forceps under the subclavian muscles to assure that the muscles are cut at the level of insertion over the first trip at the neurovascular bundle. Patients should continue physical therapy for the first two postoperative months for pain management and to decrease the risk of injury recurrence.

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Abstract