Successful Return to Active Duty after First Rib Resection for Thoracic Outlet Syndrome

Background: The optimal surgical approach and treatment algorithm for thoracic outlet syndrome (TOS) remain controversial. We sought to examine the outcomes of patients treated at a military medical treatment facility (MTF) for TOS. Methods: A retrospective review was performed on all patients who had a first rib resection (FRR) for TOS over a 9-year period at a single MTF. Patient demographics, perioperative details, and patient outcomes were examined. Active duty (AD) status and return to AD were reviewed. Results: From 2008 to 2016, 33 FRRs were performed in 32 patients. Of these, 30 patients were on AD with a mean age of 27 years (range, 19-44). The 29 male and 4 female patients were treated for symptoms of venous (23), neurogenic (6), or arterial (4) TOS. The mean time from onset of symptoms was 11 months (range, 1 to 120). The FRR was performed via a transaxillary (13), supraclavicular (12), or paraclavicular (8) approach. Of 21 AD patients with venous TOS, 16 (76%) underwent preoperative thrombolysis. A postoperative venogram or ultrasound was performed in 20 patients, documenting vein patency in 18 (90%). Nine patients underwent subsequent venoplasty or stent placement. Most patients (15) were placed on anticoagulation for 1-6 months. Two AD patients had perioperative complications including a lymph leak and brachial plexus palsy. Twenty-four (89%) patients returned to AD status. One recruit never returned to AD after successful FRR, and two other patients did not return for medical reasons unrelated to the FRR. Conclusions: Despite a variety of surgical approaches and often delayed presentation, we identified a high percentage of postoperative vein patency and return to AD status in our population. The debate over surgical approach remains; however, a multimodal approach individualized to the patient's presentation and meticulous surgical technique led to successful outcomes in our healthy military population.