Remaining or residual first ribs are the cause of recurrent thoracic outlet syndrome

Kendall Likes, Thadeus Dapash, Danielle H. Rochlin, Julie A. Freischlag

Research output: Contribution to journalArticle

Abstract

Background: Surgical intervention for neurogenic thoracic outlet syndrome (NTOS) is not always successful. Treatment plans can be difficult in patients presenting with recurrent symptoms. The purpose of this study was to evaluate outcomes of this patient subset, who underwent operative intervention to remove a remaining or residual first rib because of recurrent thoracic outlet syndrome (TOS)-related symptoms. Methods: Data on 15 patients who presented with previous scalenectomy, brachial plexus lysis, or first rib resection and scalenectomy (FRRS) with residual rib present on chest radiograph from 2004 to 2012 were retrospectively reviewed from a prospectively maintained database, with approval from the Institutional Review Board of Johns Hopkins Hospital. Patients were classified as having a remaining first rib if they presented with recurrent NTOS symptoms, had previously undergone scalenectomy and/or brachial plexus lysis alone to decompress the thoracic outlet, and exhibited an intact first rib on chest X-ray, whereas patients were classified as having a remnant rib if they presented with recurrent symptoms of NTOS, had previously undergone a first rib resection at another institution, and exhibited an anterior or posterior first rib on chest X-ray. Demographic and clinical characteristics along with postoperative outcomes were evaluated. Results: Different precipitating events reaggravated symptoms in 12 patients. Events included car accidents (n = 4), work-related repetitive movements (n = 5), lifting heavy objects (n = 2), and repetitive injury (n = 1). Group 1: Previous scalenectomy (n = 2), brachial plexus lysis alone (n = 2), or both (n = 3). Seven patients (2 men and 5 women; mean age 34 [25-53]) presented with NTOS symptoms due to a remaining first rib at an average of 24 months (range: 2-68) after their initial operation at another institution. All underwent transaxillary first rib resection, residual scalene resection, and lysis of scar tissue. Perioperative complications included 3 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 17 months (range: 1-79), and all the patients improved in the postoperative period. Group 2: Residual rib (n = 8). Eight patients (2 men and 6 women; mean age 39 [24-58]) presented with a residual first rib at an average of 44 months (range: 12-107) after their initial operation at another institution. Six patients had undergone prior supraclavicular FRRS, 1 had undergone previous transaxillary FRRS, and 1 had undergone FRRS via an anterior chest approach. Of the 8 patients, 7 presented with neurogenic symptoms alone, and 1 presented with recurrent venous thrombosis in addition. A residual rib was present in all the 8 patients, as seen by a chest radiograph. A transaxillary approach was used to resect the residual first rib, anterior scalene muscle remnant, and scar tissue in 7 patients, and a supraclavicular approach was used in 1 patient. Perioperative complications included 4 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 13 months (range: 1-64), and all the patients improved in the postoperative period. Conclusions: Patients who present with recurrent symptoms of TOS need to be evaluated for remaining or residual first ribs. Operative intervention to remove the remaining or residual first rib in this patient subset is beneficial and can be performed without significant morbidity. Patients undergoing procedures for TOS support our procedure of complete first rib removal at the time of the initial operation to prevent recurrence of symptoms.

Original languageEnglish (US)
Pages (from-to)939-945
Number of pages7
JournalAnnals of Vascular Surgery
Volume28
Issue number4
DOIs
StatePublished - 2014

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Thoracic Outlet Syndrome
Ribs
Brachial Plexus
Thorax
Arm Injuries
Pneumothorax
Postoperative Period
Cicatrix
Veins
Arteries
X-Rays

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

Remaining or residual first ribs are the cause of recurrent thoracic outlet syndrome. / Likes, Kendall; Dapash, Thadeus; Rochlin, Danielle H.; Freischlag, Julie A.

In: Annals of Vascular Surgery, Vol. 28, No. 4, 2014, p. 939-945.

Research output: Contribution to journalArticle

Likes, Kendall ; Dapash, Thadeus ; Rochlin, Danielle H. ; Freischlag, Julie A. / Remaining or residual first ribs are the cause of recurrent thoracic outlet syndrome. In: Annals of Vascular Surgery. 2014 ; Vol. 28, No. 4. pp. 939-945.
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title = "Remaining or residual first ribs are the cause of recurrent thoracic outlet syndrome",
abstract = "Background: Surgical intervention for neurogenic thoracic outlet syndrome (NTOS) is not always successful. Treatment plans can be difficult in patients presenting with recurrent symptoms. The purpose of this study was to evaluate outcomes of this patient subset, who underwent operative intervention to remove a remaining or residual first rib because of recurrent thoracic outlet syndrome (TOS)-related symptoms. Methods: Data on 15 patients who presented with previous scalenectomy, brachial plexus lysis, or first rib resection and scalenectomy (FRRS) with residual rib present on chest radiograph from 2004 to 2012 were retrospectively reviewed from a prospectively maintained database, with approval from the Institutional Review Board of Johns Hopkins Hospital. Patients were classified as having a remaining first rib if they presented with recurrent NTOS symptoms, had previously undergone scalenectomy and/or brachial plexus lysis alone to decompress the thoracic outlet, and exhibited an intact first rib on chest X-ray, whereas patients were classified as having a remnant rib if they presented with recurrent symptoms of NTOS, had previously undergone a first rib resection at another institution, and exhibited an anterior or posterior first rib on chest X-ray. Demographic and clinical characteristics along with postoperative outcomes were evaluated. Results: Different precipitating events reaggravated symptoms in 12 patients. Events included car accidents (n = 4), work-related repetitive movements (n = 5), lifting heavy objects (n = 2), and repetitive injury (n = 1). Group 1: Previous scalenectomy (n = 2), brachial plexus lysis alone (n = 2), or both (n = 3). Seven patients (2 men and 5 women; mean age 34 [25-53]) presented with NTOS symptoms due to a remaining first rib at an average of 24 months (range: 2-68) after their initial operation at another institution. All underwent transaxillary first rib resection, residual scalene resection, and lysis of scar tissue. Perioperative complications included 3 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 17 months (range: 1-79), and all the patients improved in the postoperative period. Group 2: Residual rib (n = 8). Eight patients (2 men and 6 women; mean age 39 [24-58]) presented with a residual first rib at an average of 44 months (range: 12-107) after their initial operation at another institution. Six patients had undergone prior supraclavicular FRRS, 1 had undergone previous transaxillary FRRS, and 1 had undergone FRRS via an anterior chest approach. Of the 8 patients, 7 presented with neurogenic symptoms alone, and 1 presented with recurrent venous thrombosis in addition. A residual rib was present in all the 8 patients, as seen by a chest radiograph. A transaxillary approach was used to resect the residual first rib, anterior scalene muscle remnant, and scar tissue in 7 patients, and a supraclavicular approach was used in 1 patient. Perioperative complications included 4 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 13 months (range: 1-64), and all the patients improved in the postoperative period. Conclusions: Patients who present with recurrent symptoms of TOS need to be evaluated for remaining or residual first ribs. Operative intervention to remove the remaining or residual first rib in this patient subset is beneficial and can be performed without significant morbidity. Patients undergoing procedures for TOS support our procedure of complete first rib removal at the time of the initial operation to prevent recurrence of symptoms.",
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TY - JOUR

T1 - Remaining or residual first ribs are the cause of recurrent thoracic outlet syndrome

AU - Likes, Kendall

AU - Dapash, Thadeus

AU - Rochlin, Danielle H.

AU - Freischlag, Julie A.

PY - 2014

Y1 - 2014

N2 - Background: Surgical intervention for neurogenic thoracic outlet syndrome (NTOS) is not always successful. Treatment plans can be difficult in patients presenting with recurrent symptoms. The purpose of this study was to evaluate outcomes of this patient subset, who underwent operative intervention to remove a remaining or residual first rib because of recurrent thoracic outlet syndrome (TOS)-related symptoms. Methods: Data on 15 patients who presented with previous scalenectomy, brachial plexus lysis, or first rib resection and scalenectomy (FRRS) with residual rib present on chest radiograph from 2004 to 2012 were retrospectively reviewed from a prospectively maintained database, with approval from the Institutional Review Board of Johns Hopkins Hospital. Patients were classified as having a remaining first rib if they presented with recurrent NTOS symptoms, had previously undergone scalenectomy and/or brachial plexus lysis alone to decompress the thoracic outlet, and exhibited an intact first rib on chest X-ray, whereas patients were classified as having a remnant rib if they presented with recurrent symptoms of NTOS, had previously undergone a first rib resection at another institution, and exhibited an anterior or posterior first rib on chest X-ray. Demographic and clinical characteristics along with postoperative outcomes were evaluated. Results: Different precipitating events reaggravated symptoms in 12 patients. Events included car accidents (n = 4), work-related repetitive movements (n = 5), lifting heavy objects (n = 2), and repetitive injury (n = 1). Group 1: Previous scalenectomy (n = 2), brachial plexus lysis alone (n = 2), or both (n = 3). Seven patients (2 men and 5 women; mean age 34 [25-53]) presented with NTOS symptoms due to a remaining first rib at an average of 24 months (range: 2-68) after their initial operation at another institution. All underwent transaxillary first rib resection, residual scalene resection, and lysis of scar tissue. Perioperative complications included 3 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 17 months (range: 1-79), and all the patients improved in the postoperative period. Group 2: Residual rib (n = 8). Eight patients (2 men and 6 women; mean age 39 [24-58]) presented with a residual first rib at an average of 44 months (range: 12-107) after their initial operation at another institution. Six patients had undergone prior supraclavicular FRRS, 1 had undergone previous transaxillary FRRS, and 1 had undergone FRRS via an anterior chest approach. Of the 8 patients, 7 presented with neurogenic symptoms alone, and 1 presented with recurrent venous thrombosis in addition. A residual rib was present in all the 8 patients, as seen by a chest radiograph. A transaxillary approach was used to resect the residual first rib, anterior scalene muscle remnant, and scar tissue in 7 patients, and a supraclavicular approach was used in 1 patient. Perioperative complications included 4 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 13 months (range: 1-64), and all the patients improved in the postoperative period. Conclusions: Patients who present with recurrent symptoms of TOS need to be evaluated for remaining or residual first ribs. Operative intervention to remove the remaining or residual first rib in this patient subset is beneficial and can be performed without significant morbidity. Patients undergoing procedures for TOS support our procedure of complete first rib removal at the time of the initial operation to prevent recurrence of symptoms.

AB - Background: Surgical intervention for neurogenic thoracic outlet syndrome (NTOS) is not always successful. Treatment plans can be difficult in patients presenting with recurrent symptoms. The purpose of this study was to evaluate outcomes of this patient subset, who underwent operative intervention to remove a remaining or residual first rib because of recurrent thoracic outlet syndrome (TOS)-related symptoms. Methods: Data on 15 patients who presented with previous scalenectomy, brachial plexus lysis, or first rib resection and scalenectomy (FRRS) with residual rib present on chest radiograph from 2004 to 2012 were retrospectively reviewed from a prospectively maintained database, with approval from the Institutional Review Board of Johns Hopkins Hospital. Patients were classified as having a remaining first rib if they presented with recurrent NTOS symptoms, had previously undergone scalenectomy and/or brachial plexus lysis alone to decompress the thoracic outlet, and exhibited an intact first rib on chest X-ray, whereas patients were classified as having a remnant rib if they presented with recurrent symptoms of NTOS, had previously undergone a first rib resection at another institution, and exhibited an anterior or posterior first rib on chest X-ray. Demographic and clinical characteristics along with postoperative outcomes were evaluated. Results: Different precipitating events reaggravated symptoms in 12 patients. Events included car accidents (n = 4), work-related repetitive movements (n = 5), lifting heavy objects (n = 2), and repetitive injury (n = 1). Group 1: Previous scalenectomy (n = 2), brachial plexus lysis alone (n = 2), or both (n = 3). Seven patients (2 men and 5 women; mean age 34 [25-53]) presented with NTOS symptoms due to a remaining first rib at an average of 24 months (range: 2-68) after their initial operation at another institution. All underwent transaxillary first rib resection, residual scalene resection, and lysis of scar tissue. Perioperative complications included 3 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 17 months (range: 1-79), and all the patients improved in the postoperative period. Group 2: Residual rib (n = 8). Eight patients (2 men and 6 women; mean age 39 [24-58]) presented with a residual first rib at an average of 44 months (range: 12-107) after their initial operation at another institution. Six patients had undergone prior supraclavicular FRRS, 1 had undergone previous transaxillary FRRS, and 1 had undergone FRRS via an anterior chest approach. Of the 8 patients, 7 presented with neurogenic symptoms alone, and 1 presented with recurrent venous thrombosis in addition. A residual rib was present in all the 8 patients, as seen by a chest radiograph. A transaxillary approach was used to resect the residual first rib, anterior scalene muscle remnant, and scar tissue in 7 patients, and a supraclavicular approach was used in 1 patient. Perioperative complications included 4 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 13 months (range: 1-64), and all the patients improved in the postoperative period. Conclusions: Patients who present with recurrent symptoms of TOS need to be evaluated for remaining or residual first ribs. Operative intervention to remove the remaining or residual first rib in this patient subset is beneficial and can be performed without significant morbidity. Patients undergoing procedures for TOS support our procedure of complete first rib removal at the time of the initial operation to prevent recurrence of symptoms.

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