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ObjectiveBecause of the small numbers of thoracic outlet syndrome (TOS) patients treated with bilateral first rib resection and scalenectomy (FRRS), this patient subset has not been well studied. We examined a large cohort of TOS patients who underwent bilateral FRRS to evaluate patient characteristics and outcomes.MethodsPatients treated with bilateral FRRS at Johns Hopkins Medical Institutions from 2003 to 2012 were identified by review of a prospectively maintained database. Statistical analysis compared patients with unilateral and bilateral FRRS and bilateral patients with different TOS indications.ResultsFifty-three patients underwent bilateral FRRS with a mean follow-up of 11.4 months. Average time between operations was 17.0 months (range, 5.1-59.8 months). Compared with 408 unilateral FRRS patients, bilateral patients were younger (30 vs 35 years; P = .012), with no significant difference in gender. Among patients with dual-sided FRRS, 25 (47%) had bilateral neurogenic symptoms, 2 (4%) had bilateral arterial symptoms, and 26 (49%) had venous symptoms with the first side due to intermittent compression in 5 (second side: four, intermittent compression; one, neurogenic) and effort thrombosis in 21 (second side: 9, effort thrombosis; 8, intermittent compression; 4, neurogenic). Ten patients had prophylactic FRRS to prevent contralateral venous or arterial thrombosis, and eight had cervical ribs. Compared with neurogenic patients, venous patients were younger (25 vs 35 years; P < .001), with a trend toward more competitive athletes (seven venous vs two neurogenic). Symptomatic restenosis requiring dilation occurred after four FRRS for venous symptoms at a mean of 32.4 months, and rethrombosis occurred after four FRRS at a mean of 4 weeks (one treated with warfarin, three with tissue plasminogen activator), all on the primary side. Overall, 88% of FRRS for symptomatic TOS led to resolved symptoms at last follow-up.ConclusionsBilateral FRRS is an effective method for treatment of TOS. Venous bilateral patients more often are younger, are competitive athletes, and require close postoperative monitoring for recurrent stenosis and thrombosis.

Objectives: Due to the small numbers of thoracic outlet syndrome (TOS) patients treated with bilateral first rib resection and scalenectomy (FRRS), this patient subset has not been well studied. We examined a large cohort of TOS patients who underwent bilateral FRRS to evaluate patient characteristics and outcomes. Methods: Patients treated with bilateral FRRS at Johns Hopkins Medical Institutions from 2003-2012 were identified by review of a prospectively maintained database. Statistical analysis compared patients with unilateral and bilateral FRRS, and bilateral patients with different TOS indications. Results: 53 patients underwent bilateral FRRS with a mean follow-up of 11.4 months. Average time between operations was 17.0 (range, 5.1-59.8) months. Compared to 408 unilateral FRRS patients, bilateral patients were younger (30 vs 35 years; P < .008) with no significant difference in gender. Among patients with dual-sided FRRS, 25 (47%) had bilateral neurogenic (N) symptoms, two (4%) had bilateral arterial symptoms, and 26 (49%) had venous symptoms with the first side due to intermittent compression (IC) in five (second side 4 IC, 1 N) and effort thrombosis (ET) in 21 (second side 9 ET, 8 IC, 4 N). 12 patients had prophylactic FRRS to prevent contralateral venous or arterial thrombosis, and eight had cervical ribs. Compared to neurogenic patients, venous patients were younger (25 vs 35 years; P < .002) with a trend towards more competitive athletes (7 venous vs 2 N). Symptomatic restenosis requiring dilation occurred after four FRRS for venous symptoms at a mean of 32 months, and rethrombosis occurred after four FRRS at a mean of 4 weeks (1 treated with warfarin, 3 with tPA), all on the primary side. Overall, 89% of FRRS led to resolved symptoms at last follow-up. Conclusions: Bilateral FRRS is an effective method for symptomatic and prophylactic treatment of TOS. Venous bilateral patients are more often younger, competitive athletes, and must be monitored closely postoperatively for recurrent stenosis and thrombosis.

Objective The purpose of this study was to review our operative experience in patients with thoracic outlet syndrome (TOS) resulting from cervical ribs causing clinical symptoms. Methods This study is a retrospective review of a prospectively acquired database of patients with TOS treated with first rib resection and scalenectomy with or without cervical rib resection at the Johns Hopkins Medical Institutions. Results Between October 2003 and June 2011, a total of 23 cervical rib resections were performed on 20 patients, three of whom had bilateral cervical ribs resected during separate operations. Seven patients presented with subclavian artery thrombosis. Three of seven patients had subclavian artery aneurysms and underwent cervical rib resection through a supraclavicular approach to facilitate subclavian artery bypass. Five patients presented with an ischemic upper extremity without thrombosis and underwent transaxillary first rib and cervical rib resection. Three patients presented with subclavian vein thrombosis; two of the three patients underwent balloon dilation 2 weeks postoperatively for stenosis. Additionally, five patients presented with neurogenic TOS evidenced by pain, numbness, and weakness without vascular compromise in the affected arm. Cervical ribs with bony fusion to the first rib were found in 17 of 23 cases (74%). Conclusions Cervical ribs causing clinical symptoms are large and frequently fused to the first rib, and can result in aneurysm formation or thrombosis. In our experience, both the cervical rib and the first rib must be removed to relieve arterial compression and can usually be done through a transaxillary approach. Only patients with aneurysms needing arterial reconstruction require resection of the artery from a supraclavicular approach.

Surgical management of neurogenic thoracic outlet syndrome (NTOS) is controversial due to the lack of predictors of success and difficulties in patient selection. We sought to examine the effects of patient demographics, etiology, duration of symptoms, and the selective use of lidocaine and botulinum toxin anterior scalene blocks on outcomes of patients undergoing transaxillary decompression with first rib resection and scalenotomy for NTOS.Patients with NTOS who had failed physical therapy and had transaxillary decompression between 2003 and 2009 were reviewed retrospectively from a prospectively maintained database. Patients were stratified to age groups40 and ≥ 40 years old. Bivariate and multivariate statistical models of analysis were used.One hundred fifty-nine procedures (16 patients bilateral; three patients with cervical ribs; 84.3% women; median age, 37 years; range, 21-64 years) were identified. Ninety-six patients were40 and 63 were ≥ 40 years old. Etiology was similar in both groups: trauma 43% vs 46% and chronic repetitive motion 57% vs 54%. Duration of symptoms was less in the40 group (38.4 vs 66 months; P.05). More patients in the ≥ 40 group had other spine, shoulder, or arm operations (38% vs 18%; P.05). Median follow-up for the cohort was 12 months. Transaxillary decompression was more likely to relieve symptoms in patients40 vs ≥ 40 years old (90% vs 78%; P.05). Lidocaine blocks were positive in 89% (49 of 55 patients) in the40 group and 93% (43 of 46 patients) in the ≥ 40 group. After adjusting for patient presenting factors in multivariate analysis, the impact of a successful lidocaine block in patients ≥ 40 years old was greater than in patients40 years old (improvement of surgical success of 14% in the40 group vs 7% in the40 group; P = .05). Botulinum toxin blocks were successful in less patients, 38% (eight of 21 patients) in the40 group and 52% (12 of 23 patients) in the ≥ 40 group but were not predictive of symptom relief after transaxillary decompression.Although patients with NTOS40 years old achieve more symptom relief overall after transaxillary decompression as compared to patients ≥ 40 years old, the selective use of lidocaine blocks is more beneficial in predicting surgical success in patients ≥ 40 years old given that younger patients40 years old seem to do well regardless.

ObjectiveFirst rib resection and scalenectomy (FRRS) has been shown to improve short-term quality of life (QOL) in the treatment of neurogenic thoracic outlet syndrome (NTOS). Long-term benefits are not well studied but are believed to decrease over time. Our objective was to evaluate long-term NTOS outcomes using validated QOL instruments.MethodsWe identified 162 NTOS patients aged ≥18 years treated by FRRS from 2003 to 2010 after they had not responded to conservative management. The patients were mailed three surveys to assess QOL (Short-Form 12 [SF-12], Brief Pain Inventory [BPI], and Cervical Brachial Symptom Questionnaire [CBSQ]), with five total outcomes measures including the SF-12 Physical Component Score (PCS), SF-12 Mental Component Score (MCS), BPI severity, BPI interference, and CBSQ score. Demographic and clinical data were extracted from patient records. Each FRRS was categorized based on postoperative clinical assessment as successful, failed, or leading to recurrent symptoms.ResultsSurvey yield was 53.7% (n = 87) with mean follow-up of 44.7 months (range, 12.4-91.9 months). There was no significant difference in QOL scores associated with long-term compared with short-term follow-up. Significantly poorer scores on all instruments were associated with comorbid chronic pain syndromes, opioid use, and unfavorable clinical assessment (P < .05). Significantly poorer scores on select instruments were associated with smoking (BPI both; P < .02), age ≥40 years (SF-12 PCS, BPI interference, CBSQ; P < .03), neck and/or shoulder disease (SF-12 both, BPI both; P < .01), postoperative injections (BPI both, CBSQ; P < .05), and complications (SF-12 PCS, CBSQ; P < .05). A positive preoperative scalene block was not significantly associated with long-term QOL scores.ConclusionsThe QOL after FRRS shows no significant difference with longer follow-up. Clinical assessment reflects patient-reported outcomes and can gauge postoperative improvement. Patient factors, particularly comorbidities and opioid use, are more predictive of long-term QOL than is preoperative scalene block and should also be considered when selecting patients for surgical intervention.

BackgroundSurgical treatment for neurogenic thoracic outlet syndrome does not always yield successful outcomes. The purpose of this study was to describe patients with unresolved, recurrent, and/or contralateral symptoms following first rib resection and scalenectomy (FRRS) and to determine therapies for improving their outcomes.MethodsData on 161 neurogenic thoracic outlet syndrome patients (182 FRRS procedures) were prospectively collected from 2003 to 2011 and retrospectively reviewed for evidence of unresolved, recurrent, and/or contralateral neurogenic symptoms following FRRS. Demographic and clinical characteristics, interventions, and outcomes were compared between these patients and those with a successful result.ResultsTwenty-three patients (24 FRRS) had unresolved symptoms at a mean of 16.1 ± 14.7 postoperative months. Compared with successes, these patients were older (mean age, 45 vs 38 years; P = .002) and active smokers (33% vs 13%; P = .031), with a longer duration of symptoms (90 vs 48 months; P = .005). They had higher rates of chronic pain syndromes (67% vs 14%; P < .001), neck and/or shoulder comorbidities (58% vs 22%; P < .001), preoperative opioid use (67% vs 31%; P = .001), and preoperative Botox injections (46% vs 20%; P = .009) with less relief (18% vs 64%; P = .014). Sixteen patients had recurrent symptoms at a mean of 12.1 ± 9.7 postoperative months. These patients had more chronic pain syndromes (38%; P = .028) and neck and/or shoulder comorbidities (50%; P = .027), with recurrence secondary to scar tissue (69%; P < .001) and reinjury (31%; P = .002). Postoperative treatments for both groups included physical therapy and local injections, where six unresolved (26%) and 13 recurrent (81%) patients achieved freedom from opioids at the end of the follow-up period. Twenty-one patients had contralateral symptoms and underwent secondary FRRS at a mean of 15.0 months (range, 7-30 months) following primary FRRS. The first operation was successful in 90% of cases.ConclusionsPatients with unresolved symptoms are older, active smokers with more comorbid pain syndromes, neck and/or shoulder disease, and a longer symptom duration. These patients face a more difficult recovery, whereas patients with recurrent symptoms are well managed with physical therapy and Botox injections. Patients with contralateral symptoms at >1 year are effectively treated with secondary FRRS. Patients must be followed closely after FRRS to determine if additional interventions are necessary to ensure successful results.