Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Summary

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.

Abstract

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.

Introduction

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 TOS^4,5. 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.

Protocol

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.

1. For the Adson test (scalene test, Figure 1A), 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 toward the tested shoulder. Ask the patient to breathe in and hold their breath.
   1. Consider the test positive in cases where reproduction of symptoms or abolition of the radial pulse occurs while symptoms resolve with rotating of the head to the controlateral side.
2. For the costoclavicular brace test (Figure 1B), bring the patient’s arm to the back, depress and retract over the patients' scapula on the ipsilateral side. Check the pulse. If the radial pulse disappears or symptoms are reproduced, the test is deemed positive.
3. For the hyperabduction test (Figure 1C), slightly extend the patient’s arm and palpate the radial artery. Abduct the arm 90-180°. A positive test is a decrease in the pulse of the radial artery from baseline to the new position.
4. For the Roos (East) test (Figure 1D), perform the test in either a sitting or standing position. Take the patient’s shoulders to 90° abduction, externally rotate, and flex elbows to 90°. The elbows should be slightly behind the frontal plane. Have the patient open and close his/her hands for 3 minutes.
   1. Consider the test 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.
      NOTE: Surgical treatment is the first option in VTOS cases, whereas surgical treatment is performed in NTOS cases after 3 months of conservative therapy without any improvement in their daily life, work life, and sleep quality.

2. Preoperative clinical and electrodiagnostic assessment

1. For evaluation of the clinical improvement with surgical treatment, make clinical findings in the physical examination, EMG findings, and the QuickDASH (Disability of Arm, Shoulder, and Hand: https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf) questionnaire related to symptoms of daily activities and social and psychological preoperative periods.
2. Determine the preoperative EMGs by measuring the compound motor action potential (CMAP), sensory nerve action potential (SNAP), and nerve conduction velocity (NCV) and F-wave latency. Make recordings using a commercial EMG/NCV/EP measuring system (e.g., Nihon Kohden Neuropack 2).

3. Transaxillary first rib resection in a stepwise manner

1. Perform anesthesia using a standard anesthetic induction protocol which includes 0.6 mg/kg rocuronium bromide, 0.05 mg/kg midazolam and 1-2 µg/kg fentanyl.
2. Administer tiopenthal sodium at 6 mg/kg for maintenance.

4. Patient position (Figure 2)

1. After placing the patient in the lateral decubitus position, wrap the arm, elevate and hang in a 90° abduction position. If needed, reduce traction every 3-5 minutes to prevent postoperative complication.
2. Use a solution of 10% sterile povidone-iodine for topical sterilization. Drape the arm, axilla and chest. Use sterile sheets on to rest of the body to prevent contamination.

5. Reaching the first rib

1. Use the surgical instruments are shown in Figure 3 and the Table of Materials.
2. Make an incision in a transverse fashion below the axillary hairline extending from the pectoralis muscle anteriorly and the latissimus dorsi muscle posteriorly at a length of 5-7 cm.
3. Cross the skin, subcutaneous tissue, and fascia to reach the anterior chest wall.
4. Use blunt dissection to reach the first rib.

6. Releasing the first rib from muscles and fascia

1. Pierce the fascia overlying the first rib and dissect away the periosteum overlying the superior part of the rib. Bluntly dissect the inferior edge of the rib from surrounding muscles using monopolar cautery and rib raspatory.
2. Split the intercostal muscles until the costoclavicular ligament at the sternocostal junction and the angular costa in the posterior costovertebral junction.
3. In the superior edge of the first rib, expose the anterior scalene muscle anteriorly and medius scalene muscle posteriorly. Place the curved forceps under the anterior and middle scalene muscles to cut the muscles at the level of their insertion over the first rib, where they are farthest from the neurovascular bundle.

7. Removal of the first rib or the cervical rib

1. Start the resection of the first rib at the sternocostal junction anteriorly. First, turn from its superior edge and then the inferior edge to resect it using a rib cutter from the sternum. Ensure that the neurovascular structures are preserved.
2. Afterwards, resect the posterior portion of the rib, and disarticulate the part located distally to the angle of rib; hence complete the rib resection.
3. After totally freeing the cervical rib from surrounding tissue, resect and disarticulate the rib until the articular surface of the transverse process is seen.

8. Postoperative Period

1. In postoperative period, perform a chest X-ray to rule out complications, such as pnomothorax.
2. Remove the thorax drain on postoperative day 1 in uneventful cases.
3. Use nonsteroidal anti-inflammatory drugs, narcotic analgesics, and a muscle relaxant for postoperative pain.
4. In the early postoperative period, examine movement of the arm in the operated side. Continue physical therapy for the first two post-operative months.
5. Advise the patient not to perform any exhausting activity with the operated side.

9. Postoperative clinical and electrodiagnostic assessment

1. For evaluation of the clinical improvement with surgical treatment, compare clinical findings in the physical examination, EMG findings, and the QuickDASH (Disability of Arm, Shoulder, and Hand: https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf) questionnaire related to symptoms of daily activities and social and psychological preoperative and postoperative (3 months) periods.
2. Compare the preoperative and postoperative EMGs by measuring the compound motor action potential (CMAP), sensory nerve action potential (SNAP), and nerve conduction velocity (NCV) and F-wave latency. Make recordings using a commercial EMG/NCV/EP measuring system (e.g., Nihon Kohden Neuropack 2).
3. Perform the physical examination postoperatively to evaluate the pain and paresthesia.

Results

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 ± 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...

Discussion

TFRR is the most used surgical technique for treatment of TOS^9,10,11. 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...

Materials

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