Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

This transaxillary first rib resection procedure can be used for the treatment of thoracic outlet syndrome caused by compression of brachial plexus, subclavian vein, and artery. The advantage of transaxillary first rib resection is that it has a smaller rate of recurrence and better cosmetic outcomes than standard treatment options. To perform an Adson test, bring the patient's shoulder to external rotation with slight abduction and a little bit of extension, and palpate the radial pulse.

Extend the patient's head backward and rotate the head toward the tested shoulder. Ask the patient to breathe in and hold their breath. The test is considered positive when the reproduction of symptoms or the abolition of the radial pulse occurs and the symptoms resolve with rotation of the head to the contralateral side.

For a costoclavicular brace test, bring the patient's arm to the back and depress and retract the arm over the patient's ipsilateral scapula. Check the radial pulse. If the pulse disappears or symptoms are reproduced, the test is considered positive.

For the hyperabduction test, slightly extend the patient's arm and palpate the radial artery while abducting the arm 90 to 180 degrees. A positive test is indicated by a decrease in the pulse of the radial artery from baseline to the new position. For a Roos test, with the patient in either a sitting or standing position, move the patient's shoulders to 90-degree abduction and externally rotate and flex the elbows to 90 degrees.

With the elbows slightly behind the frontal plane, have the patient open and close their hands for three minutes. The test is considered positive if the patient experiences heaviness, ischemic pain or weakness of the arms, or numbness and tingling of the hands. Discoloration of the hands is also meaningful for the test.

For evaluation of the clinical improvement with surgical treatment, record the clinical findings from the physical examination and the QuickDASH questionnaire related to the symptoms of daily activities and social and psychological preoperative periods. To determine the preoperative electromyography values, use an appropriate commercial measuring system to measure the compound motor action potential, sensory nerve action potential, nerve conduction velocity, and F-wave latency according to standard protocols. For transaxillary first rib resection after confirming sedation, place the patient in the lateral decubitus position and wrap and elevate the arm in a 90-degree abduction position.

Use a 10%sterile povidone-iodine solution for topical sterilization and drape the arm, axilla, and chest. Use sterile sheets on the rest of the body to prevent contamination. Make a five to seven-centimeter transverse incision below the axillary hairline, extending from the pectorals muscle anteriorly and the latissimus dorsi muscle posteriorly, and cross the skin's subcutaneous tissue and fascia to reach the anterior chest wall.

With the aid of a focus scope, use blunt dissection to access the first rib and to pierce the overlying fascia. Dissect the pariosteal overlying the superior part of the rib and use monopolar cautery and rib raspatory to bluntly dissect the inferior edge of the rib from the surrounding muscles. Split the intercostal muscles until the costoclavicular ligament is at the sternocostal junction and the angular costa in the posterior costovertebral junction.

In the superior edge of the first rib, expose the anterior scaling muscle anteriorly and the medial scalene muscle posteriorly. Place the curved forceps under the anterior and middle scalene muscle to cut the muscles at the level of their insertion over the first rib at the point farthest from the neurovascular bundle. Starting the resection of the first rib at the sternocostal junction anteriorly, turn a rib cutter blade from its superior edge into the inferior edge to resect the junction from the sternum, taking care that the neurovascular structures are preserved.

To complete the resection, resect the posterior portion of the rib and disarticulate the region distal to the angle of the rib. After totally freeing the cervical rib from the surrounding tissue, resect and disarticulate the rib until the articular surface of the transverse process can be observed. After the procedure, perform a chest X-ray to rule out complications, such as pneumothorax.

In uneventful cases, remove the thorax drain on postoperative day one. In the early postoperative period, examine movement of the arm and the treated side, and advise the patient to not perform any exhausting activity with the treated side. In this representative analysis, the most common complaint of the neurogenic thoracic outlet syndrome group was arm/forearm pain, numbness, and weakness of grip, and hypothenar atrophy.

Electrodiagnostic outcomes and electromyography values were evaluated preoperatively and in the postoperative period is demonstrated, and a remarkable clinical improvement between pre-op and postoperative EMG values was observed. Take care to insert the curved forceps under the subclavian muscles to assure that the muscles are cut at the level of insertion over the first trip at the neurovascular bundle. Patients should continue physical therapy for the first two postoperative months for pain management and to decrease the risk of injury recurrence.