|
Results |
C.A. MAXWELL-ARMSTRONG,* B.S.W. NOORPURI,* S. ABDUL HAQUE,* D.M. BAKER# and A.J.
LAMERTON*
*Department of Surgery, Lincoln County Hospital, Greetwells Rd, Lincoln, U.K. and #Department of Vascular Surgery, Royal
Free Hospital, Pond Street, London, U.K.
Background: Thoracic outlet compression syndrome is characterised by a variety of symptoms relating to compression of the neurovascular bundle. Though no one test is specific for the syndrome, relief of symptoms may be obtained following surgery in up to 99% of cases. Patients and Methods: The notes of 118 patients operated on in 126 operations by a single surgeon using a supraclavicular approach were reviewed. Symptoms, pre-operative investigations, and complications were all documented. Outcome at 6 weeks, 6, 12 and 24 months follow-up was also recorded. In addition,61 patients were contacted by telephone, in order to assess current level of symptoms. Results: Symptoms were predominantly motor, sensory or vasomotor, and were present for a mean of 19.6 months prior to surgery. Complications were rare, but included a pneumothorax requiring a chest drain (n=1) and infraclavicular anaesthesia (n=13). The mean duration of hospital stay was 2.1 days. At 6 weeks follow up, 86.5% of patients reported either an improvement, or complete resolution of their symptoms. Sixty-one patients were contactable, a mean of 55 months following decompression. Of these, 44 (72.1%) were either improved or asymptomatic. Conclusion: Decompression for thoracic outlet compression syndrome through a supraclavicular approach encompassing first rib resection leads to good long-term results with few complications.
Keywords: Cervical rib, thoracic outlet compression syndrome
J.R.Coll.Surg.Edinb., 46, February 2001, 35-38
Thoracic outlet compression syndrome (TOCS) is characterised by symptoms relating to compression of the neurovascular bundle by anatomical abnormalities such as cervical rib, fibrous bands, and variations in scalene musculature.1,2,3,4 Symptoms may be neurological and vasomotor, with diagnosis made after exclusion of conditions that present with similar clinical features. No one test is specific for TOCS. The treatment is surgical decompression, with relief of symptoms in between 52% and 99% of patients.5,6,7,8
A number of operations have been described to treat TOCS, including division of scalenus anterior alone (scalenectomy),9 first rib resection by transaxillary, transthoracic or posterior approaches 10,11,12 and, more recently, resection by the supraclavicular or infraclavicular routes.13,14,15 The aim of this work is to report the 12-year experience of one consultant vascular surgeon (AJL) using a supra-clavicular approach, and follows on from our previously reported series.8 This is one of the longest follow-up periods for this condition, and one of the largest personal series documented.
One hundred and thirty-eight patients underwent 146 operations (eight had bilateral procedures), over a 12-year period between October 1986 and March 1998. The casenotes of 118 patients undergoing 126 operations were available for retrospective review. In addition to patient demographics and presenting symptoms, pre-operative investigations were recorded. All patients had thoracic inlet and chest radiographs performed prior to surgery. Nerve conduction studies, angiography, and magnetic resonance imaging (MRI) were carried out in a small number of cases. Operative details were noted, although in all cases the same technique was employed. This involved division of scalenus anterior and omohyoid, where present, and resection of the first and any cervical rib, or musculocutaneous bands. This was performed in all cases through a supraclavicular approach, and a suction drain inserted in every patient. Operative complications were recorded from the notes. Patient satisfaction and overall relief of symptoms at various time courses post-operatively was documented. In addition, patients were contacted by telephone by one clinician (SAH), and current symptoms recorded. Follow-up was recorded as asymptomatic, improved, unchanged or worse.
A total of 138 patients underwent 146 operations for decompression of their TOCS. The total number of case notes available for review was 118, encompassing 126 of the total number of operations performed. The mean age of the group was 40 years (range 14-75), with a male:female ratio of 3:10. All but eight patients underwent unilateral procedures, with a right:left ratio of approximately 2:1.
Patients presented with a variety of symptoms, and a number of signs were elicited in out-patients (Table 1). These were classified as motor, sensory or vasomotor, and were present for a mean of 19.6 months (range 6 months-20 years) prior to surgery. The commonest predisposing factor for symptoms was a previous whiplash injury (n=37). Two patients had a positive family history of TOCS and, in the remainder of cases, the condition was either idiopathic or the cause not recorded in the notes. The majority of referrals for a vascular surgical opinion were from orthopaedic surgeons (n=58) followed by general practitioners (n=30). Treatment instituted before referral included physiotherapy (n=53), non-steroidal anti-inflammatory drugs (n=30), soft collar (n=25), traction (n=18), carpal tunnel or ulnar nerve decompression (n=17) and steroid injection (n=15).
Table 1: Presenting symptoms and signs
| Motor | Sensory | Vasomotor | |||
|---|---|---|---|---|---|
| Exercise-related muscle claudication | 63 (50) 1 | Proximal ache and paraesthesia | 92 (73) | Pallor | 20 (16) |
| Weak arm, decreased grip | 81 (64) | Distal numbness | 66 (52) | Cold | 26 (21) |
| Reduced shoulder movement | 35 (28) | Sensory symptoms on TIP | 30 (24) | Positive Adsons test | 32 (25) |
| Undue fatigability | 70 (56) | Blue fingers | 19 (15) | ||
| Wasting | 9 (7) | Raynauds phenenomenon | 12 (10) | ||
| Other | 7 (6) | ||||
1 Figures in parentheses represent percentages; TIP: Thoracic inlet pressure
Surgical decompression was performed as described. Operative complications included a pneumothorax requiring a chest drain (n=1), breaching of the pleura (n=13), infra-clavicular anaesthesia (n=13), and frozen shoulder (n=2). The mean duration of hospital stay was 2.1 days (range 1-8 days). There was no operative mortality in this series of patients.
Patients were reviewed in out-patients for up to 2 years following their original procedure (Table 2). All attended at 6 weeks, and in 109 cases (86.5%), symptoms were either improved or had disappeared completely. Attendance at 6, 12 and 24 months declined progressively, though the majority of patients remained asymptomatic. Sixty-one of the 118 patients whose case notes were contactable and underwent telephone interview with one clinician (SAH), using a standard proforma, in order to assess current symptoms. The mean follow-up for the group as a whole was 55.0 months (range 2-128 months). Forty-four of the 61 patients (72.1%) reported either no symptoms or an overall improvement following surgery, and 18 of these were symptom-free. Ten patients reported no change following surgery, while seven had deterioration of their original symptoms.
Table 2: Symptoms at various time points post-operatively relative to pre-operative levels
| Number of patients | Symptom free | Improved | No change | Worse | |
|---|---|---|---|---|---|
| 6 weeks | 126 (100) 1 | 42 (33) | 67 (53) | 16 (13) | 1 (1) |
| 6 months | 97 (77) | 41 (42) | 37 (38) | 18 (19) | 1 (1) |
| 12 months | 82 (65) | 42 (51) | 28 (34) | 12 (15) | 0 |
| 24 months | 68 (54) | 35 (51) | 23 (34) | 10 (15) | 0 |
| Long-term 2 | 61 (48) | 18 (30) | 26 (43) | 10 (16) | 7 (11) |
This personal series is one of the largest documented, and confirms that decompression of TOCS can be performed safely and with satisfactory long-term results. The diagnosis of TOCS is essentially clinical, and investigations are generally performed to exclude conditions such as cervical radiculopathy or neurological disorders. In common with other authors,16 however, a large number of our patients had thoracic inlet or cervical spine radiographs, in order to confirm or refute the presence of a cervical rib. Nerve conduction studies are generally felt to be unhelpful, 4,17,18 and were not used routinely. A small number of patients in this series also underwent MRI, and angiography, to exclude other diagnoses.
A number of complications of TOCS have been reported following decompression. These include neurological deficits, brachial plexopathy, causalgia and, in some cases, death. 23 Complications documented in this report include breaching of the pleura in 14 patients and infraclavicular anaesthesia in 13. Only one chest drain was required to manage the former complication. The majority of cases of infraclavicular anaesthesia occurred early on in the series, and it is now the senior authors practice to perform a nerve-sparing dissection. The low rate of wound haematomas documented may reflect the routine use of a suction drain. The incidence of complications compares favourably with those reported by other authors. Mingoli et al noted 22 pneumothoraces and eleven pleural effusions after 134 transaxillary operations.20 In addition, 12 wound infections or haematomas were seen in their series.
The results of surgical treatment are varied, with authors reporting either good or excellent results in between 24% and 100% of cases. 21,22 Approximately 85% of cases in this series had an improvement in their symptoms at 6-week follow up. This figure is comparable with the series reported by Fantini employing a supraclavicular approach, though assessment in this series of cases was at a mean of 31 months.19 There is a progressive decline in the number of patients attending follow-up at 6, 12 and 24 months, and the proportion of asymptomatic patients gradually increases. It seems likely that the benefits of surgery increases with time, up to 2 years following the initial procedure. The proportion of patients reporting no change following surgery remains constant at all follow-up points, and may reflect a group in whom the diagnosis of TOCS was incorrect at the outset. In seven cases in our series, symptoms had deteriorated at a mean follow-up of 55 months. It is possible that progressive conditions such as cervical spondylosis were causing symptoms not dissimilar to that of the TOCS. Recurrent symptoms requiring re-operation have been described, though they usually present within 2 years of the initial procedure. 24 Overall, 44 of the 61 cases (72.1%) contacted by telephone were either asymptomatic or improved by surgery, at a mean follow-up of 55 months. Lindgren and Oksala (1986) reported that 43% of 45 patients were completely asymptomatic as a result of surgery at an average of 8 years post-operatively.23 In another report, good to excellent results were observed in 96 of the 105 patients at a mean follow-up of 99 months, using a transaxillary approach.20 Our results are comparable with those reported by other authors, although a number of patients failed to attend outpatients post-operatively for long-term evaluation. This may reflect either dissatisfaction with treatment or resolution of symptoms. It is also interesting to note that an additional two patients at 6 months felt their symptoms were unchanged relative to the pre-operative status. This may suggest initial improvement followed by deterioration in these individuals. Nonetheless, it seems likely that the current symptoms (pressure and severity) obtained following telephoning individual patients is an accurate reflection of current problems statistics.
These results suggest that decompression of TOCS may be performed through a supraclavicular approach with low morbidity, and long-term relief of symptoms in a high proportion of patients. Our previously reported series only considered 50 patients, operated on before 1991.8 While those results were acceptable, this series provides further information confirming that an approach incorporating first rib resection can still be recommended.
ACKNOWLEDGEMENTS
The authors wish to thank the Audit department at Lincoln County Hospital for their invaluable help in collating this data.
Copyright date: 30th December 2000
Correspondence to Mr CA Maxwell-Armstrong DM FRCS, Department of Surgery, Queens Medical Centre, Nottingham NG7 2UH, U.K.
Email: charles.maxwell-armstrong@talk21.com
©2001 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb.