The transaxillary approach in the treatment of thoracic outlet syndrome: A neurosurgical appraisal

Object: Different surgical approaches are available for the treatment of thoracic outlet syndrome (TOS). Our aim is to describe the transaxillary approach from a neurosurgical perspective, and to present the results in 15 patients. Methods and Results: Fifteen patients (6 m and 9 f; mean age 44 yrs) were treated for neurogenic TOS. Four patients (26.7 %) demonstrated a cervical rib. The rest did not show a diagnosable bony anomaly (73.3 %). Provocative tests were neurologically positive in all patients (100%); 4 patients additionally demonstrated vascular symptoms (26.7%). Six patients demonstrated ulnar nerve F-wave latency (40%). The transaxillary approach was used in all patients. In three patients with cervical ribs (20%), an additional ventral approach was utilized. 14 patients remain symptom-free at a mean follow-up period of 24 months (93.4 %). One complained of pain recurrence at nine months after surgery and was treated conservatively (21/2 yrs). One patient developed pneumothorax after surgery (6.7%). Four patients reported on numbness of the lateral thoracic wall, due to stretch injury of the intercostobrachial nerve that lies along the approach corridor (26.7%). Conclusion: The transaxillary approach is one of several described surgical options for the treatment of TOS. It lies along a natural corridor and is non-muscle splitting. Although it requires a deep surgical corridor, the transaxillary approach allows definitive treatment of both bony and soft-tissue components causing TOS, provided the anatomical boundaries are recognized and respected. A persistent cervical rib, however, calls for an additional ventral approach. The complications are minimal and the results are predominantly acceptable.