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. (C) 2003 Elsevier B.V. All rights reserved.