Hand Clin 20 (2004) 7182

Combined surgical treatment of thoracic outlet syndrome: transaxillary rst rib resection and transcervical scalenectomy
Erdog an Atasoy, MD
Department of Surgery, University of Louisville School of Medicine, Louisville, KY Kleinert, Kutz and Associates Hand Care Center, PLLC, Suite 700, 225 Abraham Flexner Way, Louisville, KY 40202, USA

Surgical procedures performed to relieve thoracic outlet syndrome (TOS) have changed dramatically since 1861 when cervical rib resection was introduced [1]. Table 1 describes the evolution of these procedures. Presently, transaxillary rst rib resection and transcervical anterior and middle scalenectomy are the most popular and standard procedures for the surgical treatment of TOS. First rib resection is recommended for lower-level TOS (involving the C8T1 roots). Scalenectomy usually is the preferred treatment for upper-level TOS (involving the C5, C6, and C7 roots), or following whiplash injury and recurrent TOS after a previously performed rst rib resection. Markedly obese and big or excessively muscular patients also are considered candidates for scalenectomy, because complete resection of the rst rib can be dicult and carries a higher risk for these patients. In the early 1980s, some surgeons believed that combining these two procedures was the answer to complete TOS relief. They performed the scalenectomy rst and then followed with a transaxillary rst rib resection [2,3]. Since 1989 the author has combined these two surgeries but has performed the transaxillary rst rib resection rst and then followed immediately with a transcervical anterior and medial scalenectomy [4]. By perform-

E-mail address: bstewart@kleinertkurtz.com

ing these two procedures in this order the author has accomplished total decompression of the thoracic outlet area. Following a complete rst rib resection, the anterior and middle scalenectomy can be performed easily, because all of the distal insertions of these muscles have been released from the rst rib. During anterior scalenectomy, the distal insertion of the anterior scalene muscle (which was cut at the time of the rst rib resection) and the subclavian artery are clearly visible when the intact sheath of the scalene muscle is exposed and pierced with a scissor. The integrity of the artery is protected easily. During middle scalenectomy the previously divided distal end of the middle scalene muscle and the long thoracic nerve can be exposed easily once the sheath of the middle scalene muscle is cut. Nearly 80% of the anterior scalene muscle and 40%50% of the middle scalene muscle can be removed during the scalenectomy while ensuring the complete integrity of the phrenic and long thoracic nerves. During the scalenectomy, the surgeon can see the intact sheaths of both scalene muscles and remaining muscle bers of the anterior scalene muscle (which may appear attached to the subclavian artery). If these muscle sheaths and bers are left intact, they may cause the scalene muscles to become attached to the bed of the resected rst rib. Therefore, they must be cut during the scalenectomy to decrease the risk of recurrent symptoms.

0749-0712/04/$ - see front matter 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0749-0712(03)00077-5

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Table 1 Evolution of thoracic outlet syndrome surgery Name of operation Cervical rib resection First rib resection Scalenotomy First rib resection - posterior approach First rib resection - supra and infra clavicular approach First rib resection - transaxillary approach Scalenectomy Rened scalenectomy Combined approach (transaxillary rst rib resection followed immediately by transcervical anterior and medial scalenectomy) Year rst performed 1861 1908 1927 1961 1960s 1966 1938 1979 1989 Surgeon who introduced it Coote [1] Murphy [6] Adson and Coey [7] Clagett [10] Various surgeons Roos [11] Adson Sanders [12] Atasoy [4]

The technique of transaxillary rst rib resection Although several approaches have been described in the literature (ie, supraclavicular, anterior, infraclavicular, and posterior), the author has found the transaxillary approach to be the most eective. With the patient under general anesthesia, a Foley catheter is inserted into the patients bladder and the patient is positioned in the lateral position. The patients chest is turned approximately 45 50 posteriorly. A towel-covered 4inch thick foam roll is placed under the opposite axilla. One pillow is placed on the table under the patients leg that is touching the table, and another pillow is placed between the patients semiexed legs. A padded chest brace is applied to the edge of the table to support the patients chest, and a rolled 3- to 4-foot wide sheath is placed between the patients back, buttock, and the chest brace. A wide tape is applied on the hip to help stabilize the patient, and an extra strap is placed on the mid thigh for further support. Surgical preparation and draping are done on the entire upper extremity, the shoulder, the axilla, and the anterior and posterior chest walls on the surgical side. Two-layer stockinet is applied over the full length of the extremity up to the axilla. This enables full mobility of the upper extremity, which is important. Under the instruction and direction of the operating surgeon, the surgical assistant applies intermittent controlled traction on the patients arm. This is an important part of the surgery because controlled arm traction and proper wound edge retraction enable the surgeon to see

the deep part of the operative eld, the full length of the rst rib, and all vital structures. The assistant places his forearm under the forearm of the patient on the same side. He grips the patients wrist with his opposite hand and then grips his own wrist with his other hand (Fig. 1A). Roos [5] described this as the wristlock holding technique. This method enables the assistant to hold the patients arm without putting any pressure on the patients forearm nerves. It also decreases the eort required by the surgical assistant and minimizes his discomfort. Mechanical arm holding devices are not satisfactory for this purpose, because controlled, intermittent, precise arm traction that allows for an instantaneous change of direction and degree is important during the surgery, and only a human assistant can achieve this. With the patients arm fully abducted by the surgical assistant, a 5- to 6-in long smile-shaped incision is marked slightly below the axillary hairline where the axilla and chest wall meet. This marking is located near the level of the third rib (Fig. 1B). The incision is performed along the marked line, deepened through subcutaneous tissue, and then continued through the axillary fascia. During the incision, a few arterial and venous branches from the lateral axillary vessels and sometimes one or two smaller nerve branches (branches of the third intercostobrachial cutaneous nerve) can be seen. If possible these vessels are preserved, and during wound edge retraction they help to protect the nerve branches. Retraction of the skin aps with small rake-like retractors is helpful. After further deepening the dissection through the axillary fascia, which can be

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distinctive in some patients, the axillary fat pad is exposed. The axillary fatty tissue has a dierent appearance than the subcutaneous fat. The dissection is deepened directly down to the chest wall until the areolar tissue on the chest cage becomes visible. It is important to go straight down to the chest wall without disturbing the axillary lymph nodes that are present in the axillary fat pad, otherwise the axillary fat pad may be cut, the lymph nodes, and lymphatic drainage may be disturbed, and the surgeon may get lost in the operative eld. During this stage the longer ends of the Richardson retractor are used to perform wound retraction. The branches of the second and sometimes the smaller third intercostobrachial cutaneous nerves can be seen at the mid to lateral side of the operative eld, and they should be protected. These nerves innervate the posterior portion of the axilla and medial posterior upper arm skin. When the ceiling of the axilla is reached, the subclavian vein may become visible. The thin membrane that covers the top of the rst rib, the subclavian vessels, and the lower trunk is pushed gently upward with a sponge stick. This action exposes the subclavian vein, the insertion of the anterior scalene muscle to the rst rib, the subclavian artery, and the lower trunk of the brachial plexus (see Fig. 1B). Using the curved or sharp ends of the Overholt rib stripper (Fig. 1C) to continue the anterior dissection, the subclavius tendon and the costocoracoid ligament and their insertions are exposed. The dissection continues posteriorly to expose the middle scalene muscle and its wide insertion to the rst rib, and nally the T1 root of the lower trunk posteriorly. If the highest thoracic artery that is present in 30% 40% of cases is encountered, it is ligated, divided, or cauterized, depending on its size. Sometimes the rst two digitations of the serratus anterior muscle to the rst and second rib are prominent and prevent good visualization of the posterior part of the rst rib. Dividing or stripping these digitations from the rst and second ribs can resolve this problem. Evaluating the tautness of the T1 and lower trunk when the wide end of the long nger forceps touches them can determine the tension caused by the surgical assistant holding the patients arm in traction. If the surgeon notices any excessive tautness when touching the T1 and lower trunk, the assistant is asked to relax the arm. Intermittent traction and relaxation prevents ischemic and

traction injury to the brachial plexus and gives the surgical assistant a chance to rest his arms. When the rst rib is exposed anteriorly from the costochondral junction posteriorly to its neck, the important structures that are visible include the costocoracoid ligament, subclavius tendon, subclavian vein, lower portion and insertion of the anterior scalene muscle to the rst rib, subclavian artery, scalene minimus (if present), the T1 root

Fig. 1. Right transaxillary rst rib resection. (A) Marking of the incision and holding of the arm in the wristlock position. (B ) (i) Location of skin incision. (ii) Exposure of rst rib, scalene muscles, subclavian artery and vein. The dotted lines show the intended cut on the scalene muscles. (C ) Complete assortment of instruments used during a rst rib resection. Overholt rib strippers (elevators) are in top center of photograph, and to their right are Cameron Haight strippers (elevators). Rib cutters are in top left, Sauerbach rst rib rongeurs are in lower center, and large and small Richardson retractors are in upper right. (D) Schematic axillary view of right thoracic outlet anatomy with right arm fully abducted. (E ) Subperiosteal dissection of rst rib with a Cameron Haight elevator, and levering of rst rib with the handle of long nger pick-up. (F ) Cutting of rst rib in the dissected area. (G ) Removal of the anterior portion of the rst rib. (H ) Removal of the posterior portion of the rst rib. (I ) View following a 90%95% resection of the rst rib.

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Fig. 1 (continued )

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Fig. 1 (continued )

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(which emerges from under the very back portion of the rst rib and extends and joins to the C8 to form the lower trunk), and nally, the wide insertion of the middle scalene muscle to the rst rib (Fig. 1D). If the scalenus minimus muscle is present, which occurs in 30%50% of TOS cases [6,7], it usually inserts on the rst rib between the subclavian artery and T1 root of the lower trunk. Generally the dissection and mobilization of the rst rib is performed from the anterior to posterior direction. The most anterior structures, the costocoracoid ligament and the subclavius tendon insertion on the rst rib, are divided either by the sharp curved end of the Overholt stripper or by a long-handled knife, using extreme caution around the subclavian vein. Next the anterior scalene muscle is dissected carefully from the subclavian artery and vein using the blunt wide end of a long nger forceps, the unopened tip of a long dissection scissor, or even a ngertip, if the area can be reached easily. The next step is to divide the anterior scalene muscle, which can be done either by gently passing a right-angle clamp behind a portion of the muscle, pulling anteriorly, and then making a few attempts to cut it near its insertion or cutting it with a smaller bite with a long scissor. The remaining few intact bers are close to the subclavian vein and artery and they can be left alone and divided later during the removal of the rst rib. After dividing the anterior scalene muscle, attention is focused on the middle scalene muscle. Using the wide end of the long nger forceps, the subclavian artery and T1 branch of the plexus are pushed gently, achieving full exposure of the portion of the middle scalene muscle near its insertion to the rst rib. The middle scalene muscle insertion to the rst rib is cut either with a long scissor or by gently inserting a right-angle clamp under a portion of the muscle and gently pulling it o and tearing it from the rst rib. The remaining undivided, high-positioned muscle bers are pushed away from the rst rib with an Overholt or a long rib stripper. If the scalenus minimus muscle and any recognizable bands are present, they are cut at their insertion to the rst rib and a portion of them is removed. Next, the rst rib is freed from the intercostal muscles along the inferior border with the sharp, at-notched end of the Overholt rib stripper. The middle part of the rst rib is dissected approximately 2 inches along the posterior surface. Using either the at end of the Overholt stripper or preferably the wide at end of the long nger

pick-up, the rst rib is leveraged on the second rib. Then, using the at, thinner end of the Cameron Haight rib elevator, subperiosteal dissection of the rst rib is performed (Fig. 1E). The curved end of the Overholt stripper is used to continue the periosteal stripping. Next, the curved end of the most suitable Overholt stripper is passed gently under the dissected portion of the rst rib between the periosteum and the rst rib. To separate the rst rib from the soft tissue, the tip of the stripper is pushed gently upward, carefully staying close to the rst rib at the concave border. When the tip of the stripper is visible at the upper border of the rst rib, the area is scraped gently, both anteriorly and posteriorly, to make enough room to pass the rib cutter through the space. The wide end of the long nger pick-up can be used to push the lower plexus and subclavian artery gently upward. Then, using a straight rib cutter, the rst rib is divided (Fig. 1F). The anterior portion of the rib is grasped with a Kocher clamp, lifted up gently, pulled outward and dissected from the posterior periosteum. The few remaining bers of the anterior scalene muscle attached to the upper border of the rst rib are divided carefully. Dissection of the anterior portion of the rst rib is continued at least 1 cm beyond the costochondral junction. The subclavian vein is close to the upper edge of this portion of the rib and it should be protected. The costochondral junction is scored with an Overholt strippers longer, curved end. Then an attempt is made to avulse the anterior portion of the rst rib at the costochondral junction. If dissection has not been extended beyond the costochondral junction, the avulsion can tear the pleura, causing pneumothorax. If avulsion does not occur, the anterior portion of the rst rib is cut and removed (Fig. 1G). Then the sharp tips are rongeured up to the costochondral junction. Next, using a Kocher clamp or a long nger pick-up interchangeably, the posterior portion of the rst rib is lifted up, pulled outward, and dissected from the posterior periosteum and from the soft tissues along the upper and lower borders up to the transverse process of T1 vertebra. Maximum care should be given to avoid injury to the subclavian vessels and the lower portion of the brachial plexus, especially T1, which has a close relationship with the posterior portion of the rst rib. This portion of the rst rib is cut with Roos right-angle rib cutter or a straight rub cutter as far

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back as possible (Fig. 1H). A large Sauerbruchs rst rib rongeur and then a smaller size of the same rongeur are used to remove the remaining posterior portion of the rib up to the transverse process, if possible. If the transverse process of T1 cannot be reached because of the diculty in performing the dissection, no more than 1 cm of the rst rib can be left in this area. After removing the rst rib, the loose ends of both scalene muscles are trimmed as high as safety permits (Fig. 1I). Occasionally arterial bleeding may occur in the middle scalene muscle from the deep transverse cervical artery (dorsal scapular artery) or from one of its branches. Smaller bleeding can be controlled easily by applying pressure with a sponge stick or using a silver vascular clip. If the bleeding is excessive and not accessible through the axilla, an immediate scalenectomy is necessary. The bleeding can be located easily at the middle scalenectomy site and controlled quickly. If major bleeding from the subclavian vein or artery occurs during the rst rib resection, immediate action must be taken. Usually a tear in the subclavian vein is small, and because of low venous pressure, bleeding is not severe. Finger pressure, suctioning the operative eld, and suturing the tear with an interrupted or a continuous 6-0 Prolene vessel suture can control such bleeding. The size of the tear determines the severity of subclavian artery bleeding. To control bleeding in the subclavian artery, immediate pressure must be applied and then the operative eld must be suctioned, vascular clamps applied, and the tear must be stitched with 5-0 or 60 Prolene vessel sutures. During TOS surgery the rate of major vessel injury is 1% or less. After meticulous hemostasis is achieved, the wound is irrigated rst with lactated Ringers solution and then bacitracin solution (50,000 U in 1000 mL Ringers solution). Then a 1-in Penrose drain is inserted through a small stab wound just below the posterior end of the incision, and the end of the drain is placed in the high point in the axillary space just behind the T1 nerve. The drain is sutured to the skin with 5-0 nylon. Then the axillary fascia is closed with an interrupted 5-0 polyglactin suture. Skin closure is performed in two layers: several interrupted 5-0 polyglactin sutures are placed in the deep layer of the dermis including a little bit of fatty tissue below the dermis, and 5-0 polyglactin continuous sutures are placed in the dermis. Then steri-strips are applied

to the skin. The dressing should include a 4 4 pad on the incision, three to four open layers of ABD pads on the drain site, and long taping. Dressing changes should be performed at least daily and sometimes twice a day. The drain usually is removed in 48 hours. The pneumothorax incidence is less than 10% in the authors cases; if pneumothorax occurs, a small chest tube (size 28) can be inserted through the fourth or fth intercostal space at the midaxillary line and connected to pleura-vactype drainage. If the pleural tear is large enough it can be sutured and at least partially closed. The chest tube usually is removed the next day. If a cervical rib is present, is 2 in or longer, and is not articulated with the rst rib, resection of only the cervical rib is usually sucient and rst rib resection is not needed. If the cervical rib is articulated with the rst rib, usually the cervical and rst rib are removed; generally, the fusion site is removed, then the cervical rib is removed, followed by the rst rib. A cervical rib less than 1 cm does not need to be resected as long as the soft tissue attachments to the cervical rib are dissected and removed. Then a full rst rib resection is performed. If the rst rib is wide or the fusion between the rst and second ribs is wide, it may not be possible to cut this wide area completely with the bite of the straight rib cutter. In such cases a wedge resection is performed rst in the wide area. Once the area is narrowed, complete cutting can be performed easily with a straight rib cutter. In a muscular person who also may have hyperabduction syndrome (especially a male), pectoralis minor division near the coracoid should be performed as a supplement to rst rib resection, either before or after rst rib resection (preferably before). Through the same incision, the pectoralis minor is dissected from the pectoralis major, keeping its nerve supply intact and divided just below the coracoid process by using electrocautery. The most common complaint after transaxillary rst rib resection is decreased sensation associated with some paresthesias along the upper medial and posterior aspect of the upper arm. This usually is caused by traction placed on the second and third intercostobrachial cutaneous nerves during the surgery, and most of the time it is temporary. Permanent injury to the brachial plexus (usually T1 and C8) has been reported rarely. Permanent major nerve injury occurs in less than 0.5% of cases as a result of TOS surgery.

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With long thoracic nerve injury, the patient may have a mild to marked winging of the scapula. If the winging of the scapula is severe enough to disable the patients shoulder girdle motions and does not show any improvement for at least 1 year, then a scapulothoracic stabilization procedure is considered [8]. Sympathetic overactivity causing severe coldness and Raynaud phenomenon-like symptoms has been observed in some cases of TOS. In these patients, a transaxillary rst rib resection followed with a transthoracic upper extremity sympathectomy is most likely necessary (through the same incision and third intercostal space). The T4, T3, T2, and only the lower third of the stellate ganglion are removed by clipping and cutting their rami. For further details see Management of Peripheral Nerve Problems, Second Edition, 1998, Chapter Eighteen [9].

The technique of scalenectomy With the patient under general anesthesia, the chest and head are elevated approximately 40 . A long piece of 3- to 4-inch thick foam is placed across and under the shoulders to moderately hyperextend the neck, which is turned to the side opposite the surgical area. One or two pillows are placed under the knees to keep them moderately exed. Skin markings are made at the edges of the suprasternal notch, the clavicle, the AC joint, and the sternocleidomastoid and trapezium muscles. The external jugular vein, cervical plexus, and spinal accessory nerves also are marked (Fig. 2A). The skin incision is nearly 8 cm long along the skin crease and approximately 1.52 cm above the clavicle, starting at the medial border of the sternocleidomastoid muscle and extending to the anterior border of the trapezius muscle. The incision is made through the skin, subcutaneous tissue, and platysma. First, the proximal skin ap, which includes the skin, subcutaneous tissue, and platysma, is developed from the sternocleidomastoid fascia, omohyoid fascia, and prescalene fat tissue. The external jugular vein is preserved and dissection is continued upward until the lower branch of the cervical plexus is visualized or until the dissection is close to it (at the middle of the lateral border of the sternocleidomastoid muscle). During the proximal dissection, the transverse cervical branches of the cervical plexus that extend over the sternocleidomastoid fascia that are encountered are elevated with the ap and

preserved. Next the distal ap is mobilized on the omohyoid and sternocleidomastoid fascia down to its insertion to the clavicle. The distal ap should include the skin, platysma, and the full thickness fatty tissue under the platysma and over the sternocleidomastoid muscle. Using this dissection technique protects the supraclavicular branches of the cervical plexus and helps them remain in the fatty tissue of the distal ap. Then the omohyoid muscle and fascia are divided with a cutting Bovie and most of the clavicular insertion of the sternocleidomastoid muscle is divided along the top of the clavicle for better exposure of the prescalene fat and internal jugular vein (Fig. 2B). The lateral border of the sternocleidomastoid muscle is freed from the prescalene fat until the internal jugular vein becomes visible. Next the exposed prescalene fat is incised and mobilized with a dissecting scissor along the internal jugular vein, staying approximately 1 cm away from the vein on the right side and nearly 1.5 cm away on the left side, because the left side has more lymphatic tissue than the right side. This part of the dissection is a little more bloody than usual because of the abundant vascularity of the prescalene fat. All bleeding points are cauterized as the surgery progresses. The supercial (transverse) cervical artery and accompanying vein, which generally can be visualized at the lower part of the wound, are ligated and divided (Fig. 2C). During the prescalene fatty tissue mobilization, the phrenic nerve can be visualized and protected. It usually crosses the anterior scalene muscle from the lateral to medial direction, starting at the C5 root of the brachial plexus. If the phrenic nerve is located more medial than usual, the prescalene fat pad is mobilized medially rst to provide better exposure of the phrenic nerve, the ascending cervical artery, and the accompanying vein. Then the fat pad is mobilized laterally over the brachial plexus until the lateral border of the middle scalene muscle becomes visible. Next the phrenic nerve (sometimes one or two accessory phrenic nerves can be present) is mobilized gently, leaving some fatty tissue and possibly the ascending cervical artery along the nerve to maintain an abundant blood supply to the nerve. The nerve is retracted gently with a wide silastic vascular loop by the assistant surgeon. After adequate mobilization of the prescalene fat pad, the full length of the anterior scalene muscle and the lower end of the scalene sheath are well exposed. If the rst rib resection has been

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Fig. 2. Right scalenectomy. (A) Incision and supercial anatomy for a right scalenectomy. (B) Elevation of the skin aps and the exposure of the sternocleidomastoid muscle and prescalene fat. (C) Mobilization of the prescalene fat along the internal jugular vein as a laterally based ap; ligation, division of the supercial cervical artery and exposure of the phrenic nerve, and division of most of the clavicular head of the sternocleidomastoid muscle. (D) Exposure of the divided lower end of the middle scalene muscle (which was divided during the previously performed rst rib resection) and exposure of the long thoracic nerve. (E) Suturing prescalene fat along the internal jugular vein and covering the brachial plexus.

performed just before the scalenectomy, the surgeon can see some bloody uid inside the sheath of the anterior scalene muscle at its lower end. The fascia is opened carefully to expose the freshly cut and proximally retracted end of the anterior scalene muscle. The subclavian artery is visibile under the previously divided anterior scalene muscle. To get full exposure of the subclavian artery, the remaining intact muscle bers are divided carefully. Some of the bers may seem to be attached to the subclavian artery. The anterior scalene muscle is mobilized medially and laterally along the ascending cervical artery and brachial plexus respectively (C5C6 roots) and is

mobilized posteriorly upward on the bro-fatty tissue covering the C7 and C8 roots. Then it is divided at the C5 level just below the phrenic nerve takeo and is removed. Sometimes it is easier to rst divide the anterior scalene muscle proximally using traction on the muscle with a heavy pick-up below the phrenic nerve takeo from the C5. Then with the combined proximally and distally oriented dissection, the anterior scalene muscle can be removed. Next the posterior bro-fatty sheath of the anterior scalene muscle is dissected. While going through this structure and removing a portion of it, one can see (if present) the deep transverse

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Fig. 2 (continued )

cervical artery (dorsal scapular artery) that lies between the C6 and C7 and sometimes between the C7 and C8. If this artery is in the way, it can be divided and ligated to provide better exposure of the C7, C8, and T1 roots. The scalenus minimus, if present, usually lies near the C8 root, and it is removed. Following this, all branches of the brachial plexus are dissected carefully, freed,

and exposed. Usually approximately 80% of the anterior scalene muscle is removed. If the scalenectomy is the only procedure to be performed, the phrenic nerve is mobilized rst, as explained previously. Then the anterior scalene muscle is divided slowly, carefully, and completely at the middle part, keeping in mind that the subclavian artery may pass through the muscle

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substance. Next the distal portion of the anterior scalene muscle is dissected carefully from the brachial plexus, which is just lateral and posterior, the subclavian artery, which is deep and posterior, and ascending cervical artery, which is medial. The subclavian vein usually is not exposed; it is anterior to the muscle. The distal portion of the anterior scalene muscle is removed at or near its insertion to the rst rib. Then the proximal portion of the muscle is dissected and removed as described previously. Following the anterior scalenectomy, attention is directed to the middle scalene muscle. First the long thoracic nerve is exposed carefully and preserved. Its usual location is at the lateral border of the middle scalene muscle, and it exits this muscle at the junction of the middle and lower third (Fig. 2D). Sometimes an unusual location of the nerve is observed; it may exit the muscle more anteriorly through the substance of the lower part. On some occasions more than one branch of the nerve is observed, and these branches join further distally beyond the exposed area. For this reason the surgeon must be careful during the dissection, before and while dividing the middle scalene muscle. If rst rib resection has been performed just before the scalenectomy, the intact middle scalene muscle sheath is opened at its distal portion and divided lower end of the middle scalene muscle exposed (see Fig. 2D), the remaining muscle bers are cut, and usually 40%50% of the muscle is removed. During the dissection and removal of the middle scalene muscle, again full attention should be directed to the integrity of the long thoracic nerve whose branches originate from C5, C6, and C7, run through the middle scalene muscle, and join together either inside or outside the muscle. If the deep transverse cervical artery (dorsal scapular artery) is present and is in the way, it can be re-ligated and divided in the middle scalene area for better exposure of the depth of the operative eld. At the deeper area of the middle scalene space, one can see the tip of the previously inserted axillary drain. If necessary, any remaining sharp end of the rst rib that can be palpated through the middle scalene space can be exposed easily and removed with a rongeur. If the rst rib resection was not done before the scalenectomy, after exposing and protecting the long thoracic nerve, the middle scalene muscle is divided carefully at or near its insertion to the rst rib, and at least the distal one third to one half of it is removed. Following meticulous hemostasis, the wound irrigation is performed rst with a few hundred ml

of lactated Ringers solution and then bacitracin solution (50,000 U in 1000 mL lactated Ringers solution). Two small (0.25 in) drains are inserted from the lateral corner of the incision, through the prescalene fat pad, down to the middle and anterior scalene spaces. The prescalene fat pad is approximated with interrupted 5-0 polyglactin 910 (Vicryl) sutures by overlapping the medial portion onto the lateral portion to give good fatty tissue coverage to the brachial plexus (Fig. 2E). Next the platysma and deep portion of the dermis are approximated with interrupted 5-0 Vicryl sutures and the skin is closed with running dermal absorbable 5-0 Vicryl sutures. Then steri-strips are placed on the skin and a mild compression dressing is applied to the neck. Daily or twice a day dressing changes can be performed, and the drain sites can be cleaned with alcohol or hydrogen peroxide solution. The neck drains are removed in 24 hours, the axillary drain, which is inserted right after the rst rib resection, is removed in 48 hours, and the patient is discharged with postoperative instruction for wound care and active neck and shoulder range-of-motion exercises. Complications following scalenectomy may include neck hematoma, chylous drainage (mostly from the left side), occasionally long-lasting dyspnea (caused by phrenic nerve irritation or disturbed blood supply to the nerve), and rarely mild Horner syndrome. Hematoma may require surgical intervention if it is extensive. Chylous drainage may require repeated aspiration, and if it persists, surgical exploration and ligation of the lymph vessel may be necessary. Dyspnea and mild Horner syndrome require observation, although they usually improve spontaneously. From late 1989 through the end of 2002, 532 surgeries were performed in the authors institution using the combined surgical procedure for TOS. The patients on whom these surgeries were performed included 44 males and 396 females. The most common age range was 2540 years and the mean age was 38 years. The youngest patient was 10 years and the oldest was 63 years of age. Results of combined surgical procedure for TOS A simple grading system has been set up based on the patients opinions of their percentage of improvement following combined primary surgery for TOS. The rate of symptom improvement after combined primary surgery was graded empirically (Table 2).

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Table 2 Results of combined rst rib resection and scalenectomy Percent improvement 70%100% 50%70% 30%50% 10%30% Less than 10% Description Excellent Good Better Fair Very poor No of patients 36 24 26 9 5

repaired without incident. In addition, no major wound infections, neck hematomas, or chylous drainages were observed.

References
[1] Coote H. Pressure on the axillary vessels and nerve by an exostosis from cervical rib: interference with the circulation of the arm, removal of the rib and exostosis; recovery. Med Times Gazette 1861;2:108. [2] Qvarfordt PG, Ehrenfeld WK, Stoney RJ. Supraclavicular radical scalenectomy and transaxillary rst rib resection for the thoracic outlet syndrome. Am J Surg 1984;148:1116. [3] Wiley E. Discussion in Roos D.B. The place for scalenectomy and rst rib resection in TOC. Surgery 1982;92:1084. [4] Atasoy E. Thoracic outlet compression syndrome. Ortho Clin N Am 1996;27(2):265303. [5] Roos DB. Experience with rst rib resection for thoracic outlet syndrome. Ann Surg 1971;173: 42942. [6] Murphy T. Brachial neuritis caused by pressure of rst rib. Aus Med J 1910;15:5825. [7] Adson AW, Coey JR. Cervical rib: a method of anterior approach for relief of symptoms by division of the scalenus anticus. Ann Surg 1927;85:83957. [8] Atasoy E, Majd M. Scapulothoracic stabilization for winging of the scapula using strips of autogenous fascia lata. J Bone Joint Surg [Br] 2000; 82(6):8137. [9] Atasoy E, Kleinert HE. Surgical sympathectomy sympathetic blocksupper and lower extremity, local plexus level. In: Omer GE, Van Beek AL, editors. Management of peripheral nerve problems. 2nd edition. Philadelphia: WB Saunders; 1998. p. 15771. [10] Clagett OT. Presidential address: research and prosearch. J Thorac Cardiovasc Surg 1962;44:15366. [11] Roos DB. Transaxillary approach to rst rib resection to relieve thoracic outlet treatment. Ann Surg 1966;163:354. [12] Sanders RJ, Monsour JW, Gerber WF, et al. Scalenectomy versus rst rib resection for treatment of the thoracic outlet syndrome. Surgery 1979; 85:10921.

Results based on 102 respondents to a questionnaire, out of 532 surgeries.

One hundred two patients returned a mailed questionnaire regarding the outcome of their surgery. Ninety-ve percent of the patients reported improvement of their symptoms after the combined procedure. Only three patients who had surgery using the combined procedure technique developed symptomatic recurrent symptoms. These patients were operated on a second time. One of these patients had good improvement after the secondary surgery, another experienced a 30%50% improvement in symptoms, and the third had an initial improvement and 6 months later developed recurrent symptoms again. Although the author has had only three patients who have required secondary surgery for recurrent symptoms, our overall no improvement or recurrence rate after the combined procedure is 5%10%. Several patients (approximately 40%50%) [4] were diagnosed with associated peripheral nerve compression in the involved extremity and had additional surgery for their peripheral nerve compressions before or after the combined procedure. The authors complications with the combined procedure are as follows: less than 10% had pneumothorax, several patients had temporary phrenic nerve palsy caused by surgical manipulation and traction, and 1012 patients (approximately 2%) experienced neck seroma that required aspiration only. No major vessel injuries occurred, except a small tear (less than 0.5 in) in the subclavian vein in two patients, which were