Surgical management of thoracic outlet syndrome

Background: The role of surgical decompression for thoracic outlet syndrome (TOS) is not clearly established, especially for the neurological (N‐TOS) or venous (V‐TOS) variants. Reports lack objective diagnostic criteria and follow‐up. American series almost exclusively describe N‐TOS. In the authors' practice, arterial TOS (A‐TOS) is much more common. Patients are treated by a multidisciplinary team and surgery is reserved for those failing to respond to conservative measures. Methods: Data regarding assessment, diagnosis (clinical, radiology, electromyography, duplex) are collected prospectively on a database (Paradox). Independent follow‐up has categorized surgical results by structured questionnaire. Results: Of 129 patients (104 women; median age 37 years), 91 underwent transaxillary first rib resection (50 A‐TOS, 31 N‐TOS, ten V‐TOS), 24 had a supraclavicular scalenectomy (rib resection; all N‐TOS) and 14 had a combined procedure (five A‐TOS, nine N‐TOS). Eleven were reoperations. Early results (6 months) were available for 122 patients. Overall 91 per cent of patients with A‐TOS rated the outcome as excellent/good, compared with 72 per cent of those with N‐TOS and nine of ten with V‐TOS. Life‐table analysis confirmed a durable outcome at up to 6 years. Of 30 patients with A‐TOS for whom data were complete, postoperative duplex imaging was normal in 28.Operation Complete relief Minor symptoms Major symptoms No improvementFirst rib resection 45 (50) 23 (25) 8 (9) 4 (4) Supraclavicular scalenectomy 3 (52) 9 (21) 5 (12) 6 (14)Conclusion: Careful patient selection following a concerted effort at conservative management yields good results. These data are useful for counselling patients who may be facing surgery for this disabling condition. © 2000 British Journal of Surgery Society Ltd