November 16, 2006

Is First Rib Resection Always Necessary for Thoracic Outlet Decompression?

David C. Cassada, MD, Michael H. Lebow, MD, Trent L. Prault, MD, Oscar H. Grandas, MD, Scott L. Stevens, MD, Michael B. Freeman, MD, Mitchell H. Goldman, MD.
University of Tennessee, Knoxville, TN, USA.

Objectives: Controversy exists over treating thoracic outlet syndrome (TOS) and what constitutes adequate surgery. We analyzed our management of TOS for surgical timing, and relationship of rib resection to morbidity and early functional outcome.
Methods: We reviewed records for diagnosis confirmation, physical therapy(PT), and surgical approach including first rib resection with scalenectomy versus scalenectomy alone. Endpoints included morbidity, reoperation, and return to work.
Results: Between July 2002 and June 2006, 279 patients were referred for arm symptoms: 44 non-TOS causes for pain included cervical radiculopathy (22), thromboangiitis obliterans (3), and orthopedic/undetermined causes(19). Twenty-six had venous TOS requiring surgery; twenty-two patients underwent decompression for arterial complications of TOS. One hundred and seventy-seven had neurogenic TOS. Those with a cervical rib (16), muscle wasting due to TOS (3), and failure of three months of physician-guided PT (n=71, see table) underwent thoracic outlet decompression by supraclavicular approach. Decision for first rib resection occurred after intraoperative assessment of brachial plexus compression.


Treatment	Mortality	Adverse events	Hospital stay (days)	Reoperation	Work	Time to Work (days)
PT alone (n-96)	0	0	0	0	88%	66.2
Rib resection (n=46)	1	14	3.8	9	67%	88.4
Scalenectomy (n=25)	0	4	1.8*	4	71%^@	84.4

*p < .05, t- test, ^@ p=NS
Conclusions: Neurogenic TOS does not usually require surgical decompression for relief of symptoms. After failure of PT, surgery, to include resection of the first rib, can be performed selectively. When “deboning” is performed, morbidity and in-hospital recovery time increases. There appears to be no difference in short-term functional outcome or need for reoperation between surgical groups .

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