Recurrent thoracic outlet syndrome R i c h a r d J. Sanders, M D , Craig E. H a u g , M D , and William H. Pearce, MD,*
Denver, Colo., and Chicago, Ill. Recurrent symptoms develop in 15% to 20% of patients undergoing either first rib resection or scalenectomy for thoracic outlet syndrome. Over the past 22 years 134 operations for recurrence were performed in 97 patients. Four operations were used: transaxillary first rib resection (26); supradavicular first rib resection with neurolysis (15); scalenectomy with neurolysis (58); and brachial plexus neurolysis (35). Complications included temporary plexus injury (0.7%), temporary phrenic palsy (3.7%), and permanent phrenic palsy (1.4%). The combined primary success rate of all four operations for recurrence was 84% in the first 3 months. This fell to 59% at 1 to 2 years; 50% at 3 to 5 years; and 41% at 10 to 15 years. No significant difference was found in results between the four operations used for recurrence. When recurrence was caused by trauma the results of reoperatious were better than when recurrence was spontaneous. The primary success rates of three initial operations for thoracic outlet syndrome were compared to their secondary success rates (improved after reoperation). By use of life-table methods, reoperation improved the 5- to 10-year success rate of transaxiUary first rib resection from 69% to 86% and for scalenectomy from 69% to 84%. Reoperation is successful in most cases of recurrent thoracic outlet syndrome and better when recurrence is the result of a neck injury. (J VASC SURG 1990;12:390-400.) First rib resection or scalenectomy improves symptoms in more than 70% o f patients with thoracic outlet syndrome (TOS), whereas 15% to 20% experience recurrence. 1-4The recurrent symptoms develop at varying time intervals after the primary operation and frequently mimic the initial presenting symptoms. These recurrent symptoms have been treated in a variety o f ways. In patients who have undergone first rib resection, scalenectomy from a supraclavicular approach is advocated. Likewise, if the patient initially underwent a scalenectomy, first rib resection is performed for the recurring symptoms. The purpose of this article is to examine in detail the operative indications and outcomes of 134 operations performed for recurrent TOS over a 22year period. The effect of reoperation on the success rates of primary operations for TOS is also examined. The statistical concept of primary and secondary success rates, similar to primary and secondary patency rates for vascular grafts, is introduced. From the Department of Surgery, Rose Medical Center and the University of Colorado Health Sciences Center, Denver, and Northwestern UniversityMedical School, Chicago.~ Supported in part by a grant from the Rose Foundation,Denver, Colo. Presented at the Fifth Annual Meeting of the Western Vascular Society, Coronado, Calif.,Jan 25-28, 1990, Reprint requests: Richard J. Sanders, MD, 4545 E. 9th Ave., Denver, CO 80220. 24/6/23498 390
MATERIAL AND METHODS Between 1966 and 1987, 134 operations fGr recurrent TOS were performed in 97 patients; 18 patents had bilateral procedures. We had performed the initial operation in 76 cases, and in 58 instances someone else had performed the previous surgery. In 11 patients a total of 19 additional operations were carried out for repeat recurrence on the same side. Three operations were performed for persistent symptoms after transaxillary first rib resection. Ten operations were carried out for persistent hand and arm symptoms in patients who had improved head and neck symptoms after scalenectomy. The other 121 procedures were performed for recurrence after an interval of improvement. The patients' ages ranged from 18 years to 55 years with a mean of 32 years. There were 77 women (79%) and 20 men (21%). Fifty percent of recurrences developed within 6 months and 80% within 2 years of the primary operation. No difference was found in the time o f recurrence after either scalenectomy or rib resection. The time between the initial operation and the reoperation ranged from 1 month to 20 years, with 50% occurring within 24 months of the first procedure. The duration of recurrent symptoms before reoperation was 1 to 45 months with a median of 11 months. Symptoms. The symptoms were often similar to those that preceded the initial operation, with slight
Volume 12 Number 4 October 1990
Recurrent thoracic outlet syndrome
391
Table I. Indications for different reoperations for recurrent TOS First or previous operation(s) Scalenectorny Transaxillary first rib resection Scalenectomy and first rib resection
Reoperation
No. reoperations
TransaxiUary rib resection Supraclavicular rib resection Scalenectomy with neuolysis
26 15 58
Brachial plexus neurolysis via supraclavicular route Neurolysis of C-8 and T-1 via transaxillary route
34
Total
variations. The most common symptoms were paresthesia in the hand (82%) and pain in the neck (73%), shoulder (71%), and arm (62%). The par,'sthesia most often involved all five fingers, but fiequently the f o m ~ and fifth fingers were worse or involved alone. Occipital headaches, weakness of the arm, and aggravation of the symptoms when elevating the arms were other common complaints. Occasional patients had chest pain. Physical examination. Supraclavicular tenderness over the scalene muscles or above the scar where scalenectomy had been performed was present in 81% of the patients. Pressure in this area usually caused paresthesia or pain in the arm, elbow, or hand. Abducting the arms to 90 degrees in external rotation (90 degree AER position) reproduced the patient's symptoms in 84%. Loss of the radial pulse in the 90 degree AER position occurred in only 12%. Other common findings were reduced range of motion of the neck when rotating the neck from one side to the other and causing pain on the symptomatic side qf the neck by tilting the head to the opposite side. Other areas were evaluated for associated or differential diagnoses. These included the shoulder joint, the biceps/rotator cuff tendons, the cervical and dorsal spine, and the wrist area for carpal runnel compression. D I A G N O S T I C TESTS
Scalene area block. In 86 patients a diagnostic test was carried out by the infiltration of 1% lidocaine hydrochloride (Xylocaine) into the anterior scalene muscle or the scar tissue in the anterior scalene area in patients ha whom scalenectomy had already been performed. A positive response was improvement in the range of motion of the neck and fewer symptoms with the arms in the 90 degree AER position. Radiography. Cervical spine films were obtained to detect cervical ribs and other bony abnormalities that might have been missed at the initial operation.
1 134
Radiography also revealed the status of resected first ribs, the existence of a long posterior or anterior stump, signs of first rib regeneration, cervical ribs, cervical arthritis, or suggestions of a cervical disc. Angiography and plethysmography. Indications for arteriography and plethysmography were ischemic symptoms in the fingers, reduced arm pressure, or reduced pulses at rest. Indications for venography were swelling or distended arm veins. These findings were seldom present, so few patients received these studies. Neurophysiologic diagnostic studies. Indications for electromyography and nerve conduction velocities were clinical suspicion of ulnar nerve entrapment at the elbow, median nerve compression at the wrist, or primary nerve injury. SURGICAL P R O C E D U R E S
Four different reoperations were performed: scalenectomy; transaxillary first rib resection; supraclavicular first rib resection with brachial plexus neurolysis; and brachial plexus neurolysis alone. The choice of procedure depended on what had been performed at the previous operation as outlined in Table I. If the first operation was rib resection, reoperation was scalenectomy; if the first operation had been scalenectomy, reoperation was first rib resection. Early in the study rib resections were performed through the transaxillary approach. After 1980 most rib resections were performed by supraclavicular approach, so a brachial plexus neuroplasty could be achieved simultaneously. In patients who had already undergone both rib resection and scalenectomy, reoperation was initially a supradavicular brachial plexus neurolysis. If ulnar nerve compression symptoms persisted after supraclavicular neurolysis, transaxillary neurolysis of C-8 and T-1 was carried out at a later time. This was done only once in the course of this study. The techniques of scalenectomy and first rib re-
392 Sanders,Haug, and Pearce
section have been described previously and are similar to those used when that operation is performed for the first time. ss However, even though most operations for recurrence are performed through different incisions than the first operation, scar tissue is encountered around the brachial plexus and subclavian artery. This makes the reoperation more difficult than the primary operation and may require localized neurolysis by use of some of the techniques described below. Neurolysis was performed alone when both rib resection and scalenectomy had been previously accomplished. It was usually performed through the supraclavicular approach by use of a 7 to 10 cm incision 2 cm above the clavicle. Superior and inferior skin flaps were elevated, and the lateral edge of the sternocleidomastoid muscle was freed and retracted medially. It was not necessary to divide the lateral head of the sternocleidomastoid muscle. The omohyoid muscle was often encountered below the sternocleidomastoid muscle and divided, it was not reapproximated when closing. The scalene fat pad was bluntly separated t o expose the lateral portion of the brachial plexus. The internal jugular vein was not sought. If this vein was seen, the dissection had proceeded too far medially. Usually the plexus was covered with scar tissue. Dissection began laterally, where C-5 and C-6 were often fused as the superior trunk of the plexus. A fine curved hemostat and pediatric right-angle hemostat were excellent tools. Scar tissue was gently freed and excised from each nerve. The anterior surfaces of C5, C-6, and C-7 were freed first. When previous supradavicular dissections had been done, the phrenic nerve was buried in scar tissue and difficult to identify. in these cases it was assumed that the phrenic nerve lay medially, and no attempt was made to dissect it from the scar tissue for fear of injuring it. As dissection proceeded from lateral to medial, vertical running fibers were tested with a nerve stimulator to see if they were the phrenic nerve. Once C-7 had been freed, the procedure usually did not proceed further medially in the plane anterior to the brachial plexus. After freeing C-5, C-6, and C-7 the dissection moved lateral and deep to C-5, looking for the neck of the first rib, if it was still evident by radiography. This was dissected free and excised. A Raney neurosurgical rongeur, a duck bill rongeur, and an Urschell first rib rongeur were used as needed to remove the posterior renmant of the rib back to its articulation with the transverse process. Safe exposure of
Journal of VASCULAR SURGERY
the neck of the rib usually required mobilizing the lateral edge of C-5 and C-6 to their full extent so they could gently be pushed medially and not damaged. Next, scar tissue was removed from behind C-5, C-6, and C-7, the area of the middle scalene muscle. Any portion of the muscle that was remaining from previous surgery was also removed. The long thoracic nerve was in this area, deep to C-5, in the unresected portions of the middle scalene muscle. This nerve was usually identified and spared. However, if the long thoracic nerve was not easily identified, additional efforts to find it were not pursued. Scar tissue around C-8 was encountered medial and posterior to C-7. it was removed if it could be done with good vision and without stretching C-5, C-6, or C-7. If these nerves had to be stretched ,'~ see C-8, the procedure was terminated without dissecting C-8. When a wide space existed between C6 and C-7, this plane was used to free C-8 instead of going lateral to C-5. The wound was closed by approximating the scalene fat pad over the nerves, leaving a suction drain deep to the plexus, and closing the skin with a running subcuticular suture. Statistical methods. Results were graded excellent, ifaU symptoms were relieved; good, if the major symptoms were relieved; fair, if a few symtoms were relieved but some major symptoms persisted; and poor, if there was no significant improvement. Since the life-table method was used to express the staffstics, only success or failure is recognized. 9 Excellent and good results were considered successes; fair improvement was classified with poor results in the life table. The log rank test was used to evaluate differences in life-table results between each of the sever~" operations. 1° Chi-square analysis was used to test for statistical significance among other variables. Primary and secondary success. Success rates were defined as primary or secondary in a way similar to that used to define vascular graft patency rates. 1~ Primary success is improvement of symptoms with no further operations. Because this study dealt only with cases of recurrent or persistent TOS, the term primary success refers to the result of each of the 134 reoperations individually. Patients receiving more than one reoperation on a given side had each operation except the last one listed as a failure. If the last procedure was successful, it was the only one so classified. Secondary success rate includes each operative side only once. The results in the 11 patients who received 19 additional reoperations are graded as the
Vokune 12 Number 4 October 1990
Recurrent thoracic outlet syndrome 393
8O
°°%°°°
% Success 60 50
..... ~... •
40
TRAUMA
N=36
'Q .............. .....
[ ] NOTRAUMA N=98 OPEN ( C ) ) =PRIMARY SUCCESS SOLID ( • ) =SECONDARYSUCCESS
30 1-: M o s
I 1-2 Yrs
I 3-5 Yrs
~-.,.,;
0
........ ~ ........................... I::]
I 5-10 Yrs
10-15 Yrs
Fig. 1. Success rate after initial reopcration (primary success, open symbols) and subsequent reoperations (secondary success, solid symbols).
result of the last operation only: if the last was successful, that patient-side was counted as one success. The time at which the last procedure failed was recorded as the failure time for that patient-side. In Fig. 1, the definitions of primary and secondary success are slightly different because this figure describes the first operation in a group of 668 patients previously reported.~2 In these patients the definition of success using life-table method was good and excellent, as well as fair results. If the fair results had been classified as failures, success rates at each terval would be reduced about 10%. Seventy six patients (12%) in this group received reoperations. The term secondary success is applied to the improvement rate of the entire group as a result of reoperation. RESULTS Success rates. Initial improvement after all 134 reoperations was 84%. This diminished to 59% at 1 to 2 years and to 50% at 3 to 5 years. Even after 5 years recurrence was seen, further reducing the success rate to 41% at 10 to 15 years (Table II). No statistically significant difference was found between the results of the four operations (p = >0.05 for all comparisons). The life table for all 134 cases is presented in Table III. The three patients who had persistent rather than recurrent symptoms after their initial first rib resec-
tions did poorly after reoperation by scalenectomy: two patients had inirnediate failure, and the third recurred 18 months after operation. Ten patients were reoperated on by transaxillary first rib resection because their primary anterior and middle scalenectomy had given them relief of their head and neck symptoms but did not help their hand and arm symptoms. Seven of these 10 patients enjoyed good longterm improvement after first rib resection. T r a u m a and primary and secondary success. A neck injury, invariably from a whiplash type automobile accident, was the cause of recurrence in 36 of the 134 cases (27%). In these patients the results of reoperation were better than when symptoms recurred spontaneously. This is not apparent from the primary success rate of trauma versus nontrauma cases in Fig. 1 until it is appreciated that haft of the failures in the traumatic group were due to another injury. They were successfiflly operated on again, and improvement is revealed in the secondary success rate of 71% at 1 to 2 years, which remained unaltered for the next 10 years. The difference between primary- and secondary success rates for nontrauma cases was not statistically significant (p --- >0.05), whereas the difference between the two for trauma cases was significant for the first year (p = 0.05), perhaps because the size of the samples became so small.
394
Journal of VASCULAR SURGERY
Sanders, H a u g , a n d Pearce
Table II. Success rate of each reoperative proccdure Operation Transaxillary first rib resection Supraclavicular rib resection & Neuolysis Scalenectomy and neurolysis Brachial plexus neurolysis Total of all reoperations
No. patients
1 to 3 mo
I to 2 yr
3 to 5 yr
5 to 10 yr
10 to 15 yr
26
69% (26)*
64% (13)
50% (11)
42%(8)
15
93% (15)
77% (10)
34% (3)
34% (3)
58
91% (58)
55% (33)
53% (25)
41% (22)
36% (14)
35 134
80% (35) 84% (134)
52% (23) 59% (79)
48% (15) 50% (54)
43% (12) 42% (45)
43% (7) 41% (25)
42% (4)
*Numbers in parentheses are cases at risk in that time interval.
Table III. Results of 134 reoperations
Time (mo)
No. operations at risk*
Not , followed to end period~
Good and excellent
Fair
Poor
Percent failed in period~:
Cumulative success (%)§
1-3 4-6 7-9 10-12 13-24 25-36 37-60 61-120 121-180
134 113 95 86 79 67 54 45 25
0 11 2 2 1 5 8 10 13
113 95 86 80 67 54 45 28 11
9 6 3 3 4 3 0 2 1
12 1 5 0 8 6 1 4 0
21/134 (15.7%) 7/108 (6.5%) 8/94 (8.5%) 3/85 (3.5%) 12/79 (15%) 9/64 (14%) 1/50 (2%) 6/40 (15%) 1/18 (5.6%)
91% 79% 72% 70% 59% 51% 50% 42% 41%
No. failed No. at beginning - 1/2 withdrawals *Number of operations at risk = number of operations at beginning of time interval. t N o t followed to end period = not followed to the end of the time interval; patient was either lost or operated on too recently for that time period. ~:Percent failed in period = combined fair and poor results are failures. §Gttmulative success percent = cumulative success rate.
Life-table formula: Failure in an interval =
The secondary success rate for trauma cases was significantly better than the primary success rate for nontrauma cases (p = 0.1). The difference between primary and secondary success rates for each of these two operations was statistically significant for all time intervals beyond 6 months (p =
Denver, Colo., and Chicago, Ill. Recurrent symptoms develop in 15% to 20% of patients undergoing either first rib resection or scalenectomy for thoracic outlet syndrome. Over the past 22 years 134 operations for recurrence were performed in 97 patients. Four operations were used: transaxillary first rib resection (26); supradavicular first rib resection with neurolysis (15); scalenectomy with neurolysis (58); and brachial plexus neurolysis (35). Complications included temporary plexus injury (0.7%), temporary phrenic palsy (3.7%), and permanent phrenic palsy (1.4%). The combined primary success rate of all four operations for recurrence was 84% in the first 3 months. This fell to 59% at 1 to 2 years; 50% at 3 to 5 years; and 41% at 10 to 15 years. No significant difference was found in results between the four operations used for recurrence. When recurrence was caused by trauma the results of reoperatious were better than when recurrence was spontaneous. The primary success rates of three initial operations for thoracic outlet syndrome were compared to their secondary success rates (improved after reoperation). By use of life-table methods, reoperation improved the 5- to 10-year success rate of transaxiUary first rib resection from 69% to 86% and for scalenectomy from 69% to 84%. Reoperation is successful in most cases of recurrent thoracic outlet syndrome and better when recurrence is the result of a neck injury. (J VASC SURG 1990;12:390-400.) First rib resection or scalenectomy improves symptoms in more than 70% o f patients with thoracic outlet syndrome (TOS), whereas 15% to 20% experience recurrence. 1-4The recurrent symptoms develop at varying time intervals after the primary operation and frequently mimic the initial presenting symptoms. These recurrent symptoms have been treated in a variety o f ways. In patients who have undergone first rib resection, scalenectomy from a supraclavicular approach is advocated. Likewise, if the patient initially underwent a scalenectomy, first rib resection is performed for the recurring symptoms. The purpose of this article is to examine in detail the operative indications and outcomes of 134 operations performed for recurrent TOS over a 22year period. The effect of reoperation on the success rates of primary operations for TOS is also examined. The statistical concept of primary and secondary success rates, similar to primary and secondary patency rates for vascular grafts, is introduced. From the Department of Surgery, Rose Medical Center and the University of Colorado Health Sciences Center, Denver, and Northwestern UniversityMedical School, Chicago.~ Supported in part by a grant from the Rose Foundation,Denver, Colo. Presented at the Fifth Annual Meeting of the Western Vascular Society, Coronado, Calif.,Jan 25-28, 1990, Reprint requests: Richard J. Sanders, MD, 4545 E. 9th Ave., Denver, CO 80220. 24/6/23498 390
MATERIAL AND METHODS Between 1966 and 1987, 134 operations fGr recurrent TOS were performed in 97 patients; 18 patents had bilateral procedures. We had performed the initial operation in 76 cases, and in 58 instances someone else had performed the previous surgery. In 11 patients a total of 19 additional operations were carried out for repeat recurrence on the same side. Three operations were performed for persistent symptoms after transaxillary first rib resection. Ten operations were carried out for persistent hand and arm symptoms in patients who had improved head and neck symptoms after scalenectomy. The other 121 procedures were performed for recurrence after an interval of improvement. The patients' ages ranged from 18 years to 55 years with a mean of 32 years. There were 77 women (79%) and 20 men (21%). Fifty percent of recurrences developed within 6 months and 80% within 2 years of the primary operation. No difference was found in the time o f recurrence after either scalenectomy or rib resection. The time between the initial operation and the reoperation ranged from 1 month to 20 years, with 50% occurring within 24 months of the first procedure. The duration of recurrent symptoms before reoperation was 1 to 45 months with a median of 11 months. Symptoms. The symptoms were often similar to those that preceded the initial operation, with slight
Volume 12 Number 4 October 1990
Recurrent thoracic outlet syndrome
391
Table I. Indications for different reoperations for recurrent TOS First or previous operation(s) Scalenectorny Transaxillary first rib resection Scalenectomy and first rib resection
Reoperation
No. reoperations
TransaxiUary rib resection Supraclavicular rib resection Scalenectomy with neuolysis
26 15 58
Brachial plexus neurolysis via supraclavicular route Neurolysis of C-8 and T-1 via transaxillary route
34
Total
variations. The most common symptoms were paresthesia in the hand (82%) and pain in the neck (73%), shoulder (71%), and arm (62%). The par,'sthesia most often involved all five fingers, but fiequently the f o m ~ and fifth fingers were worse or involved alone. Occipital headaches, weakness of the arm, and aggravation of the symptoms when elevating the arms were other common complaints. Occasional patients had chest pain. Physical examination. Supraclavicular tenderness over the scalene muscles or above the scar where scalenectomy had been performed was present in 81% of the patients. Pressure in this area usually caused paresthesia or pain in the arm, elbow, or hand. Abducting the arms to 90 degrees in external rotation (90 degree AER position) reproduced the patient's symptoms in 84%. Loss of the radial pulse in the 90 degree AER position occurred in only 12%. Other common findings were reduced range of motion of the neck when rotating the neck from one side to the other and causing pain on the symptomatic side qf the neck by tilting the head to the opposite side. Other areas were evaluated for associated or differential diagnoses. These included the shoulder joint, the biceps/rotator cuff tendons, the cervical and dorsal spine, and the wrist area for carpal runnel compression. D I A G N O S T I C TESTS
Scalene area block. In 86 patients a diagnostic test was carried out by the infiltration of 1% lidocaine hydrochloride (Xylocaine) into the anterior scalene muscle or the scar tissue in the anterior scalene area in patients ha whom scalenectomy had already been performed. A positive response was improvement in the range of motion of the neck and fewer symptoms with the arms in the 90 degree AER position. Radiography. Cervical spine films were obtained to detect cervical ribs and other bony abnormalities that might have been missed at the initial operation.
1 134
Radiography also revealed the status of resected first ribs, the existence of a long posterior or anterior stump, signs of first rib regeneration, cervical ribs, cervical arthritis, or suggestions of a cervical disc. Angiography and plethysmography. Indications for arteriography and plethysmography were ischemic symptoms in the fingers, reduced arm pressure, or reduced pulses at rest. Indications for venography were swelling or distended arm veins. These findings were seldom present, so few patients received these studies. Neurophysiologic diagnostic studies. Indications for electromyography and nerve conduction velocities were clinical suspicion of ulnar nerve entrapment at the elbow, median nerve compression at the wrist, or primary nerve injury. SURGICAL P R O C E D U R E S
Four different reoperations were performed: scalenectomy; transaxillary first rib resection; supraclavicular first rib resection with brachial plexus neurolysis; and brachial plexus neurolysis alone. The choice of procedure depended on what had been performed at the previous operation as outlined in Table I. If the first operation was rib resection, reoperation was scalenectomy; if the first operation had been scalenectomy, reoperation was first rib resection. Early in the study rib resections were performed through the transaxillary approach. After 1980 most rib resections were performed by supraclavicular approach, so a brachial plexus neuroplasty could be achieved simultaneously. In patients who had already undergone both rib resection and scalenectomy, reoperation was initially a supradavicular brachial plexus neurolysis. If ulnar nerve compression symptoms persisted after supraclavicular neurolysis, transaxillary neurolysis of C-8 and T-1 was carried out at a later time. This was done only once in the course of this study. The techniques of scalenectomy and first rib re-
392 Sanders,Haug, and Pearce
section have been described previously and are similar to those used when that operation is performed for the first time. ss However, even though most operations for recurrence are performed through different incisions than the first operation, scar tissue is encountered around the brachial plexus and subclavian artery. This makes the reoperation more difficult than the primary operation and may require localized neurolysis by use of some of the techniques described below. Neurolysis was performed alone when both rib resection and scalenectomy had been previously accomplished. It was usually performed through the supraclavicular approach by use of a 7 to 10 cm incision 2 cm above the clavicle. Superior and inferior skin flaps were elevated, and the lateral edge of the sternocleidomastoid muscle was freed and retracted medially. It was not necessary to divide the lateral head of the sternocleidomastoid muscle. The omohyoid muscle was often encountered below the sternocleidomastoid muscle and divided, it was not reapproximated when closing. The scalene fat pad was bluntly separated t o expose the lateral portion of the brachial plexus. The internal jugular vein was not sought. If this vein was seen, the dissection had proceeded too far medially. Usually the plexus was covered with scar tissue. Dissection began laterally, where C-5 and C-6 were often fused as the superior trunk of the plexus. A fine curved hemostat and pediatric right-angle hemostat were excellent tools. Scar tissue was gently freed and excised from each nerve. The anterior surfaces of C5, C-6, and C-7 were freed first. When previous supradavicular dissections had been done, the phrenic nerve was buried in scar tissue and difficult to identify. in these cases it was assumed that the phrenic nerve lay medially, and no attempt was made to dissect it from the scar tissue for fear of injuring it. As dissection proceeded from lateral to medial, vertical running fibers were tested with a nerve stimulator to see if they were the phrenic nerve. Once C-7 had been freed, the procedure usually did not proceed further medially in the plane anterior to the brachial plexus. After freeing C-5, C-6, and C-7 the dissection moved lateral and deep to C-5, looking for the neck of the first rib, if it was still evident by radiography. This was dissected free and excised. A Raney neurosurgical rongeur, a duck bill rongeur, and an Urschell first rib rongeur were used as needed to remove the posterior renmant of the rib back to its articulation with the transverse process. Safe exposure of
Journal of VASCULAR SURGERY
the neck of the rib usually required mobilizing the lateral edge of C-5 and C-6 to their full extent so they could gently be pushed medially and not damaged. Next, scar tissue was removed from behind C-5, C-6, and C-7, the area of the middle scalene muscle. Any portion of the muscle that was remaining from previous surgery was also removed. The long thoracic nerve was in this area, deep to C-5, in the unresected portions of the middle scalene muscle. This nerve was usually identified and spared. However, if the long thoracic nerve was not easily identified, additional efforts to find it were not pursued. Scar tissue around C-8 was encountered medial and posterior to C-7. it was removed if it could be done with good vision and without stretching C-5, C-6, or C-7. If these nerves had to be stretched ,'~ see C-8, the procedure was terminated without dissecting C-8. When a wide space existed between C6 and C-7, this plane was used to free C-8 instead of going lateral to C-5. The wound was closed by approximating the scalene fat pad over the nerves, leaving a suction drain deep to the plexus, and closing the skin with a running subcuticular suture. Statistical methods. Results were graded excellent, ifaU symptoms were relieved; good, if the major symptoms were relieved; fair, if a few symtoms were relieved but some major symptoms persisted; and poor, if there was no significant improvement. Since the life-table method was used to express the staffstics, only success or failure is recognized. 9 Excellent and good results were considered successes; fair improvement was classified with poor results in the life table. The log rank test was used to evaluate differences in life-table results between each of the sever~" operations. 1° Chi-square analysis was used to test for statistical significance among other variables. Primary and secondary success. Success rates were defined as primary or secondary in a way similar to that used to define vascular graft patency rates. 1~ Primary success is improvement of symptoms with no further operations. Because this study dealt only with cases of recurrent or persistent TOS, the term primary success refers to the result of each of the 134 reoperations individually. Patients receiving more than one reoperation on a given side had each operation except the last one listed as a failure. If the last procedure was successful, it was the only one so classified. Secondary success rate includes each operative side only once. The results in the 11 patients who received 19 additional reoperations are graded as the
Vokune 12 Number 4 October 1990
Recurrent thoracic outlet syndrome 393
8O
°°%°°°
% Success 60 50
..... ~... •
40
TRAUMA
N=36
'Q .............. .....
[ ] NOTRAUMA N=98 OPEN ( C ) ) =PRIMARY SUCCESS SOLID ( • ) =SECONDARYSUCCESS
30 1-: M o s
I 1-2 Yrs
I 3-5 Yrs
~-.,.,;
0
........ ~ ........................... I::]
I 5-10 Yrs
10-15 Yrs
Fig. 1. Success rate after initial reopcration (primary success, open symbols) and subsequent reoperations (secondary success, solid symbols).
result of the last operation only: if the last was successful, that patient-side was counted as one success. The time at which the last procedure failed was recorded as the failure time for that patient-side. In Fig. 1, the definitions of primary and secondary success are slightly different because this figure describes the first operation in a group of 668 patients previously reported.~2 In these patients the definition of success using life-table method was good and excellent, as well as fair results. If the fair results had been classified as failures, success rates at each terval would be reduced about 10%. Seventy six patients (12%) in this group received reoperations. The term secondary success is applied to the improvement rate of the entire group as a result of reoperation. RESULTS Success rates. Initial improvement after all 134 reoperations was 84%. This diminished to 59% at 1 to 2 years and to 50% at 3 to 5 years. Even after 5 years recurrence was seen, further reducing the success rate to 41% at 10 to 15 years (Table II). No statistically significant difference was found between the results of the four operations (p = >0.05 for all comparisons). The life table for all 134 cases is presented in Table III. The three patients who had persistent rather than recurrent symptoms after their initial first rib resec-
tions did poorly after reoperation by scalenectomy: two patients had inirnediate failure, and the third recurred 18 months after operation. Ten patients were reoperated on by transaxillary first rib resection because their primary anterior and middle scalenectomy had given them relief of their head and neck symptoms but did not help their hand and arm symptoms. Seven of these 10 patients enjoyed good longterm improvement after first rib resection. T r a u m a and primary and secondary success. A neck injury, invariably from a whiplash type automobile accident, was the cause of recurrence in 36 of the 134 cases (27%). In these patients the results of reoperation were better than when symptoms recurred spontaneously. This is not apparent from the primary success rate of trauma versus nontrauma cases in Fig. 1 until it is appreciated that haft of the failures in the traumatic group were due to another injury. They were successfiflly operated on again, and improvement is revealed in the secondary success rate of 71% at 1 to 2 years, which remained unaltered for the next 10 years. The difference between primary- and secondary success rates for nontrauma cases was not statistically significant (p --- >0.05), whereas the difference between the two for trauma cases was significant for the first year (p = 0.05), perhaps because the size of the samples became so small.
394
Journal of VASCULAR SURGERY
Sanders, H a u g , a n d Pearce
Table II. Success rate of each reoperative proccdure Operation Transaxillary first rib resection Supraclavicular rib resection & Neuolysis Scalenectomy and neurolysis Brachial plexus neurolysis Total of all reoperations
No. patients
1 to 3 mo
I to 2 yr
3 to 5 yr
5 to 10 yr
10 to 15 yr
26
69% (26)*
64% (13)
50% (11)
42%(8)
15
93% (15)
77% (10)
34% (3)
34% (3)
58
91% (58)
55% (33)
53% (25)
41% (22)
36% (14)
35 134
80% (35) 84% (134)
52% (23) 59% (79)
48% (15) 50% (54)
43% (12) 42% (45)
43% (7) 41% (25)
42% (4)
*Numbers in parentheses are cases at risk in that time interval.
Table III. Results of 134 reoperations
Time (mo)
No. operations at risk*
Not , followed to end period~
Good and excellent
Fair
Poor
Percent failed in period~:
Cumulative success (%)§
1-3 4-6 7-9 10-12 13-24 25-36 37-60 61-120 121-180
134 113 95 86 79 67 54 45 25
0 11 2 2 1 5 8 10 13
113 95 86 80 67 54 45 28 11
9 6 3 3 4 3 0 2 1
12 1 5 0 8 6 1 4 0
21/134 (15.7%) 7/108 (6.5%) 8/94 (8.5%) 3/85 (3.5%) 12/79 (15%) 9/64 (14%) 1/50 (2%) 6/40 (15%) 1/18 (5.6%)
91% 79% 72% 70% 59% 51% 50% 42% 41%
No. failed No. at beginning - 1/2 withdrawals *Number of operations at risk = number of operations at beginning of time interval. t N o t followed to end period = not followed to the end of the time interval; patient was either lost or operated on too recently for that time period. ~:Percent failed in period = combined fair and poor results are failures. §Gttmulative success percent = cumulative success rate.
Life-table formula: Failure in an interval =
The secondary success rate for trauma cases was significantly better than the primary success rate for nontrauma cases (p = 0.1). The difference between primary and secondary success rates for each of these two operations was statistically significant for all time intervals beyond 6 months (p =
