Most patients with neurologic thoracic outlet syndrome

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1 ORIGINAL ARTICLES: GENERAL THORACIC Upper Plexus Thoracic Outlet Syndrome: Optimal Therapy Harold C. Urschel, Jr, MD, and Maruf A. Razzuk, MD Division of Thoracic and Cardiovascular Surgery, The University of Texas Southwestern Medical School and Baylor University Medical Center, Dallas, Texas Background. Previously, transaxillary first rib resection alone was not considered adequate therapy for upper plexus (median nerve) thoracic outlet syndrome. It was thought that the combined approach with upper plexus dissection through a supraclavicular incision in addition to the transaxillary approach was necessary. However, with better understanding of anatomy that the median nerve receives fibers from C8 and T1 as well as the upper plexus and that muscles that compress the upper plexus attach to the first rib it is now recognized that first rib removal alone will relieve upper plexus compression. Methods. Assessment of 2,210 operations for thoracic outlet syndrome revealed 250 patients (11%) had symptoms and nerve conduction velocity slowing of the median nerve only (upper plexus), whereas 452 (20%) patients had both median and ulnar nerve compression (upper and lower), and 1,508 patients exhibited compression symptoms and nerve conduction velocity slowing of the ulnar nerve alone (lower plexus). Results. Transaxillary first rib resection relieved symptoms of median nerve (upper plexus) compression as well as it did for ulnar nerve (lower plexus) compression. Treatment outcome comparisons of patients with median and ulnar compression show no significant differences. Conclusions. These data refute the need for supraclavicular or combined supraclavicular and transaxillary approaches to treat patients with upper plexus (median) thoracic outlet syndrome compression as previously recommended. The transaxillary approach alone is satisfactory. (Ann Thorac Surg 1997;63:935 9) 1997 by The Society of Thoracic Surgeons Most patients with neurologic thoracic outlet syndrome (TOS) requiring operation have been successfully managed with transaxillary resection of the first rib. However, for upper plexus (median nerve) compression, many authors [1, 2] thought that transaxillary rib resection alone was not enough and that it should be combined with the supraclavicular approach to achieve the best results. Upper plexus compression was initially described by Swank and Simeone [3] with symptoms secondary to C5, C6, and C7 nerve root compression. Sensory changes were primarily in the first three fingers and muscle weakness or pain in the anterior chest, triceps, deltoids, and parascapular muscle areas as well as down the outer arm to the extensor muscles of the forearm. In contrast, lower plexus irritation involves C8 and T1 nerve root compression and includes sensory changes primarily in the fourth and fifth fingers with muscle weakness or pain from the rhomboid and scapular muscles to the posterior axilla down the ulnar distribution to the forearm involving the elbow, flexors of the wrist, and intrinsic muscles of the hand. Roos [2], Urschel [4], and Wood and associates [5] expanded the upper plexus symptoms to involve pain in the neck, face, mandible, and ear with occipital headaches. Woods [6] noted dizziness, vertigo, and Presented at the Forty-third Annual Meeting of the Southern Thoracic Surgical Association, Cancun, Mexico, Nov 7 9, Address reprint requests to Dr Urschel, 3600 Gaston Ave, 1201 Barnett Tower, LB 161, Dallas, TX blurred vision in some patients with upper plexus lesions. The rationales for transaxillary first rib resection alone relieving upper plexus symptoms are several. Anatomic observations show that the median nerve, usually incriminated in upper plexus compression of C5, C6, and C7 nerve roots, also receives fibers from C8 and T1 nerve roots (Fig 1). In addition, most muscles and ligaments that compress the upper plexus attach to the first rib. Thus, removing the first rib with release of all the muscles and ligaments involved theoretically relieving upper plexus compression. The purpose of this study was to evaluate only the transaxillary first rib resection (without a combined supraclavicular incision) for relief of upper plexus compression with regard to the above hypothesis as well as for comparison with surgical results from the same procedure for lower plexus compression. Material and Methods To better assess the optimal management of upper plexus thoracic outlet syndrome, we have reviewed 2,210 primary operations for TOS in 1,988 patients, 222 undergoing bilateral transaxillary resections, over a period of 30 years. Two hundred fifty operations were for symptoms, signs, and nerve conduction velocities showing median nerve or upper plexus compression only. Four hundred fifty-two were for compression of both the median and ulnar nerves or the combination of upper plexus and lower plexus by symptoms, signs, and nerve 1997 by The Society of Thoracic Surgeons /97/$17.00 Published by Elsevier Science Inc PII S (97)

936 URSCHEL AND RAZZUK Ann Thorac Surg UPPER PLEXUS TOS THERAPY 1997;63:935 9 Fig 1. Brachial plexus. Note the contribution of C8 and T1 to the median nerve. conduction velocities.

2 936 URSCHEL AND RAZZUK Ann Thorac Surg UPPER PLEXUS TOS THERAPY 1997;63:935 9 Fig 1. Brachial plexus. Note the contribution of C8 and T1 to the median nerve. conduction velocities. One thousand five hundred eight operations were carried out for symptoms, signs, and nerve conduction velocities demonstrating predominately ulnar nerve or lower plexus compression. This study does include venous or arterial patients. More than 8,000 nerve conduction velocity studies were performed at Baylor University Medical Center for many years with approximately 2,000/year demonstrating TOS. Most cases were successfully treated medically. Patients ages ranged from 14 to 63 years with a mean of 38.5 years. There were 1,294 operations performed in women and 916 in men. Diagnosis Each patient with TOS was carefully evaluated by history and physical examination and the appropriate laboratory studies, including median and ulnar nerve conduction velocities across the thoracic outlet. symptoms/signs. Pain was present in the neck, shoulder, arm and hand, chest, scapula, or combinations of these areas. Paresthesias (numbness, tingling, or both) were noted in the arms and hands. Weakness was manifested by the usual assessment in addition to the patients reporting dropping things. If headaches were present, they usually radiated up from the posterior neck. Increased sensitivity to cold, increased sweating, or color changes were often noted in the extremity and hand. Most patients noted difficulty working over head. Tenderness over the supraclavicular area (Spurling s test), provocation of symptoms that develop when the arms are abducted to 90 degrees in external rotation (Roos test), a loss or decrease of pulse due to Adson s or modified Adson s maneuver, and evidence of muscle pain or weakness in the various muscle groups were carefully documented. laboratory tests. Chest and cervical spine roentgenograms were performed to detect bony or other abnormalities. Magnetic resonance imaging or computed tomographic scan of the neck was carried out in most patients to rule out ruptured disk, spinal stenoses, or other neurologic abnormalities. Electromyograms were performed on all patients and were usually normal in TOS. Somatosensory evoked potentials were unreliable in our experience. Measurement of ulnar and median nerve conduction velocities was performed on all patients with a technique previously reported by Caldwell and associates [7]. Median nerve slowing (with corresponding symptoms) indicated upper plexus compression, whereas ulnar nerve slowing (with appropriate symptoms) indicated lower plexus compression. The normal range for nerve conduction velocities was between 72 and 85 m/s. From 60 to 72 m/s, mild compression was demonstrated, usually improving with physiotherapy or conservative treatment alone. Fifty to 60 m/s was associated with moderately severe compression, and less than 50 m/s was associated with severe compression. All patients operated on, in addition to the clinical symptoms and signs, had nerve conduction ve-

3 Ann Thorac Surg URSCHEL AND RAZZUK 1997;63:935 9 UPPER PLEXUS TOS THERAPY 937 locities demonstrating TOS. The range was from 38 to 62 m/s. In many cases where symptoms recurred, repeat conduction velocity tests were carried out to assess excessive scarring producing recurrent compression. differential diagnosis. A series of examinations were performed to differentiate TOS from other causes of similar symptoms and signs. Superior pulmonary sulcus carcinoma and esophageal or cardiac disease were excluded by the appropriate tests. conservative management. All patients were treated conservatively with physical therapy except those with vascular problems. The primary goals of physical therapy are to open up the space between the clavicle and first rib, improve posture, strengthen the shoulder girdle, and loosen the neck muscles. This is accomplished by pectoralis stretching, strengthening muscles between shoulder blades, assumption of good posture, and active neck exercises including chin tuck, flexion, rotation, lateral bending, and circumduction. Surgical Therapy indications. Operation was indicated if there was persistence of symptoms in spite of appropriate physical therapy, arterial aneurysm or vascular insufficiency, venous occlusion (Paget-Schroetter syndrome), or as a therapeutic trial with multiple areas of compression. operative technique: transaxillary approach. The patient is placed in the lateral position with the involved extremity gently supported by forearm traction straps attached to an overhead pulley with 0.5 to 1 kg of weight. An arm holder provides appropriate traction and relaxation. After the axilla and forearm are prepared and draped, a transverse incision is made below the hairline between the pectoralis major and the latissimus dorsi muscles. The dissection is carried to the chest wall and extended cephalad to the first rib. Care is taken to prevent injury to the intercostobrachial cutaneous nerve, which passes between the first and second ribs to the subcutaneous tissue in the center of the operative field. With gentle dissection, the neurovascular bundle is identified and its relation to the first rib and both scalene muscles is clearly outlined to avoid injury to these structures. The scalenus anticus muscle is divided and resected up into the neck to avoid reattachment. The first rib is dissected subperiosteally and carefully separated from the underlying pleura to avoid pneumothorax. The rib is divided and a triangular portion removed with the vertex of the triangle at the scalene tubercle. The anterior portion of the rib is dissected carefully from the vein, the costoclavicular ligament is divided, and the rib is divided at its sternal cartilaginous attachment. The anterior venous compartment is thus decompressed. The posterior segment of the rib is carefully dissected subperiosteally from the subclavian artery and brachial plexus posteriorly. The scalenus medius muscle is dissected from the rib. The rib is divided near its articulation with the transverse process of the vertebra. Complete removal of Table 1. Evaluation of Results Rating Pain Relief Employment the neck and head of the first rib is achieved by a long, specially reinforced, double-action Urschel-pituitary and Leksell rongeurs. The eighth cervical and first thoracic nerve roots undergo careful neurolysis. If a cervical rib is present, it is removed and the seventh cervical nerve root is decompressed. Meticulous hemostasis is accomplished. Only the subcutaneous tissues and skin require closure, because no large muscles have been divided. The patient is encouraged to use the arm normally and can be discharged from the hospital on the second day after the surgical procedure. It is preferable to remove the entire first rib, including its head and neck, to avoid future irritation of the plexus, because a residual portion, particularly if it is long, may cause recurrence of symptoms. The periosteum should be excised to prevent callus formation and regeneration of the rib. For recurrent symptoms, removal of incompletely resected or regenerated rib and lysis of adhesions can best be accomplished through the posterior high thoracoplasty approach. Postoperative Assessment All patients were evaluated at 3 weeks, 3 months, and yearly thereafter. The least follow-up was 3 years. Each patient was assessed by both the surgeon and the physiatrist. Results were described according to Table 1, which provides four ratings for excellent to poor based on pain relief and employment and recreation limitation. There was no mortality. Bleeding and infection occurred in less than 1% of the patients. There were no major nerve injuries. Transient paresthesias were frequent. Results Recreation Limitation Excellent Complete Full None Good Almost complete Full Some Fair Partial Limitation Moderate Poor None No return Severe The results are presented in Table 2. Of 250 operations for upper plexus lesions alone (median nerve), 71% had excellent results, 26% good results, 2% fair results, and Table 2. Results Rating Lower Plexus (Ulnar) Upper Plexus (Median) Combined Excellent Good Fair Poor Total 1,

4 938 URSCHEL AND RAZZUK Ann Thorac Surg UPPER PLEXUS TOS THERAPY 1997;63:935 9 less than 1% had poor results. Of the 1,508 procedures on patients exhibiting symptoms of ulnar nerve compression (lower plexus), 76% achieved an excellent result, 20% a good result, 4% a fair result, and less than 1% a poor result. Of 450 operations involving both ulnar and median compression (upper and lower plexus combined), 71% had excellent results, 26% good results, 3% fair results, and less than 1% poor results. In patients with fair and poor results, many were found to have recurrent TOS clinically as well as by conduction velocity suggesting excessive scar. All were treated conservatively for at least 6 months and most improved. However, 25% (24 patients) of the group including fair and poor results were reoperated on. This operation was carried out through the posterior approach. Extensive neurolysis of the brachial plexus with magnification was necessary. Dorsal sympathectomies were performed on all reoperated patients to enhance the neurolysis effect and diminish the causalgia or reflex sympathetic dystrophy (sympathetic maintained pain syndrome) [8]. A high percentage of the patients (87%) with fair and poor results had been exposed to previous trauma. There is no significant difference in the results and relief of symptoms from upper or lower plexus compression after transaxillary first rib resection. Comment The response of transaxillary rib resection therapy in this series was similar for both upper and lower plexus TOS compression. Upper plexus compression symptoms were relieved by transaxillary rib resection as well as the lower plexus compression. Thus, there would seem to be no need to add a combined supraclavicular approach. Similar findings were reported by Wood and Ellison [9] and Sanders and Pearce [10] for transaxillary resection of the first rib and neurolysis of the brachial plexus alone. This is in contrast to Roos [2] and Cheng and Stoney [11], who recommend adding the supraclavicular to the transaxillary approach for upper plexus lesions. In a separate group of vascular patients who were operated on by the combination of supraclavicular and transaxillary or by the supraclavicular approach alone, the results were no better for upper plexus compression than those reported by the transaxillary approach alone. Two published reports compare the results of operation for the upper and lower plexus symptoms. Sanders [12] classified the results in 692 operations in relation to upper, lower, and combined plexus lesions. No significant differences in outcome were found in the three groups regardless of which approach to operation was employed. This is corroborated by our findings. In 181 patients with 211 transaxillary first rib resections, Wood and Ellison [9] demonstrated that the transaxillary approach alone provided excellent relief for upper plexus TOS symptoms. There was no need to perform a combined approach or add the supraclavicular incision. Wood and Ellison believe that when scalenectomy alone is successful in patients with upper plexus lesions, it is because both the anterior and middle scalene muscles are resected rather than just the usual anterior scalenotomy or scalenectomy. They note that during the transaxillary first rib resection, the muscles are avulsed from the rib. They believe this is why patients with median nerve (upper plexus) symptoms enjoy as good a result from this approach as those with compression of the lower plexus. In performing the neurolysis of the brachial plexus, all fibers, bands, adhesions, and muscle fibers are removed. Mackinnon and associates [13, 14] emphasize the multiple crush syndrome in certain patients who demonstrate many points of compression on a given nerve. These may include a cervical disk, TOS, compression at the elbow and carpal tunnel, and many other possible places along the upper extremity. Less compression is required to produce symptoms if there are multiple points of compression, according to this multiple crush hypothesis. A carpal tunnel as well as ulnar nerve release at the elbow may all be necessary in addition to first rib resection for a patient with TOS. Many patients in our series had other points of compression relieved surgically. They are not mutually exclusive. Mackinnon [15] also suggests the gold standard of pain relief is a self report using a visual analogue scale, which was not employed in this study. It is important to take a complete and careful history and perform a meticulous physical examination involving sensory and motor deficits in the whole upper extremity. Reliable, reproducible nerve conduction velocities document the area(s) of compression and serve as a baseline for conservative and surgical therapy. They also separate nicely the upper and lower plexus compression when correlated with symptoms. The electromyogram should be normal, ruling out other neurologic problems for most of these patients. Trauma was involved in more than 50% of patients. Anatomic abnormalities explaining some upper plexus compression mechanisms involving muscle and nerve compression were described by Roos [16] and reviewed by Wood and associates [5]. References 1. Qvarfordt PG, Ehrenfeld WK, Stoney RJ. Supraclavicular radical scalenectomy and transaxillary first rib resection for the thoracic outlet syndrome: a combined approach. Am J Surg 1984;148: Roos DB. The place for scalenectomy and first rib resection in thoracic outlet syndrome. Surgery 1982;92: Swank RL, Simeone FA. The scalenus anticus syndrome. Arch Neurol Psychiatry 1944;51: Urschel HC Jr. The John H. Gibbon, Jr., Memorial Lecture: thoracic outlet syndromes. Presented at the Annual Meeting of the American College of Surgeons, San Francisco, CA, Oct 10 15, Wood VE, Twito R, Verska JM. Thoracic outlet syndrome: the results of first rib resection in 100 patients. Orthop Clin North Am 1988;19: Woods WW. Personal experiences with surgical treatment of 250 cases of cervicobrachial neurovascular compression syndrome. J Int Coll Surg 1965;44: Caldwell JW, Crane CR, Krusen EM. Nerve conduction studies in the diagnosis of the thoracic outlet syndrome. South Med J 1971;64:

5 Ann Thorac Surg URSCHEL AND RAZZUK 1997;63:935 9 UPPER PLEXUS TOS THERAPY Urschel HC Jr, Razzuk MA. The failed operation for thoracic outlet syndrome: the difficulty of diagnosis and management. Ann Thorac Surg 1986;42: Wood VE, Ellison DW. Results of upper plexus thoracic outlet syndrome operation. Ann Thorac Surg 1994;58: Sanders RJ, Pearce WH. The treatment of thoracic outlet syndrome: a comparison of different operations. J Vasc Surg 1989;10: Cheng SWK, Stoney RJ. Supraclavicular reoperation for neurogenic thoracic outlet syndrome. J Vasc Surg 1994;19: Sanders RJ. Thoracic outlet syndrome: a common sequela of neck injuries. Philadelphia: Lippincott, Mackinnon SE, Dellon AL. Surgery of the peripheral nerve. New York: Thieme, Mackinnon SE, Patterson GA, Urschel HC Jr. Thoracic outlet syndromes. In: Pearson FG, Graeber GM, eds. Thoracic surgery. New York: Churchill Livingstone, Mackinnon SE. Thoracic outlet syndrome [Editorial]. Ann Thorac Surg 1994;58: Roos DB. Transaxillary approach for first rib resection to relieve thoracic outlet compression syndrome. Ann Surg 1966;163: DISCUSSION DR LAURENS R. PICKARD (Houston, TX): Doctor Urschel, you have informed us in the past about some of the medical-legal problems associated with this condition, but a question has come up in my mind about some people who have written about the etiology of the condition associated with trauma, sometimes even minor trauma, like whiplash injuries, and so I was really interested in what you thought about that. DR URSCHEL: Of the fair and poor group of patients, about 85% of them had traumatic experiences. The worst trauma seems to be the whiplash, resulting from being hit from behind and causing a cervical syndrome as well as thoracic outlet syndrome. This group does not do as well as the group in which the condition came on spontaneously without trauma. Clavicular traumas, eg, secondary to motorcycle accidents, with callus of the clavicle, do extremely well with first rib resection and neurolysis. (The clavicle is not usually removed.) We have had only 40 cases where we have taken the clavicle out, some of them on both sides, but generally you do not have to do that. Workmen s compensation with malingering has been associated with poor results. Without conduction studies on these pain problems, I think it is difficult clinically. If somebody has a marked improvement in the conduction velocity and is complaining, it is much easier to treat that patient conservatively. On the other hand, if the conduction velocities are depressed, reoperation may well be necessary. INVITED COMMENTARY In a field such as thoracic outlet syndrome in which the subject itself is so complex and poorly defined, it is refreshing to see some clarity of focus brought to bear on a subset of cases such as has been done by Urschel and Razzuk. They describe concisely and clearly an anatomic basis for their thesis of the pathogenesis of thoracic outlet syndrome and correlate it nicely with clinical applications and outcome. Too often in the literature on thoracic outlet syndrome have there been observations and recommendations based upon subjective and poorly formulated visceral conclusions resulting in imprecise evaluations and clinical management (both operative and nonoperative) based upon poorly formulated concepts. Using a timehonored, scientific-based approach, Urschel and Razzuk present data that are refreshing and credible. W. Gerald Rainer, MD Department of Surgery University of Colorado Health Sciences Center 2005 Franklin St, Suite 380 Denver, CO by The Society of Thoracic Surgeons /97/$17.00 Published by Elsevier Science Inc PII S (97)00221-X

Objective Diagnosis (Ulnar Nerve Conduction Velocity) and Current Therapy of the Thoracic Outlet Syndrome

Objective Diagnosis (Ulnar Nerve Conduction Velocity) and Current Therapy of the Thoracic Outlet Syndrome Harold C. Urschel, Jr., M.D., Maruf A. Razzuk, M.D., Richard E. Wood, M.D., Manaharlal Parekh,