Transaxillary approach in thoracic outlet syndrome: the importance of resection of the first-rib.

OBJECTIVE The aim of this study was to analyze the transaxillary surgical approach and results of thoracic outlet cases in our clinic in the light of the recent literature data. METHODS Between 1996 and 2002 a series of 35 cases diagnosed as thoracic outlet syndrome (TOS) hospitalized and surgically treated in our clinic have been studied retrospectively. RESULTS Twenty-six of our cases were females (75%) and the mean age was 25+/-1 (17-40 years). The most important symptom was localized pain in the arm. In 90% of the cases the Adson, hyperabduction and abduction external rotation (AER) tests were positive. There was paresthesia in 30 cases (85%), atrophy in 3 cases (10%), and cyanosis in 6 cases (20%). Preoperative electromyogram (EMG) was demonstrated as 56.7 m/s (50-65) and postoperative EMG was demonstrated as 65.1 m/s (60-71). Postoperative EMG values were significantly higher than the preoperative EMG values (p<0.001). All patients were operated using the transaxillary approach. A total number of 40 operations were performed. Upon radiological investigation (n=17) 50% of the patients were found to have cervical ribs. In 30 cases (85%) the results were very good and in four cases (12%) good, and in one case (3%) the results were bad. There was no recurrence and reoperation in the long term follow-up. CONCLUSION Careful patient history and physical examination should be done by a team, which consists of thoracic surgeon, physical therapy specialist, and a neurologist. Total resection of the first-rib with periosteally should be preferred in all of these cases with accompanying pathologies such as cervical rib, fibrous ligaments, and scalenius muscles. The transaxillary approach has provided a good exposure for the resection of cervical ribs, the first-rib and excision of fibrous ligaments and scalenius muscle by a perfect cosmetic result. All the patients should be encouraged for 2 months of physical exercises starting from early postoperative period.