Anatomically-Complete Supraclavicular Reoperation for Recurrent Neurogenic Thoracic Outlet Syndrome: Clinical Characteristics, Operative Findings, and Long-Term Follow-Up
Momodou L Jammeh, MD1, J. Westley Ohman, MD1, Chandu Vemuri, MD2, Ahmmad A. Abuirqeba, BA1 and Robert W Thompson, MD1, (1)Washington University School of Medicine, St. Louis, MO, (2)Michigan Medicine, University of Michigan, Ann Arbor, MI
Introduction: Optimal approaches and clinical outcomes for surgical treatment of recurrent neurogenic thoracic outlet syndrome (NTOS) remain undefined. The purpose of this study was to assess clinical characteristics, operative findings and long-term outcomes in a large single-institution series of patients that underwent anatomically-complete supraclavicular (SC) reoperation for recurrent NTOS.
Materials & Methods: From June 2009 to April 2019 there were 1561 operations performed for NTOS in our institution, including 90 SC reoperations conducted after previous operations performed elsewhere that used either supraclavicular (Prev-SC, n = 48), transaxillary (Prev-TA, n = 31) or multiple/combination (Prev-MC, n = 11) approaches. Data from a prospectively maintained database were used for retrospective analysis.
Results: The mean (± SE) age of the 90 patients was 39.9 ± 1.4 years and 72% were female. All patients met established clinical diagnostic criteria for recurrent NTOS at a mean interval of 49.0 ± 7.8 months after previous operation. The mean duration of the elevated arm stress test was 92 ± 6 seconds and the mean DASH (Disability of the Arm, Shoulder, and Hand) score was 62 ± 2, reflecting substantial preoperative disability. Each patient underwent SC exploration with thorough brachial plexus neurolysis and complete resection of any remaining scalene muscle, fibrous bands, and/or first rib. Residual scalene muscle was present in 100% Prev-TA, 79% Prev-SC, and 55% Prev-MC (Chi-square P < 0.05). Residual first rib or significant remnants were present in 90% Prev-TA, 75% Prev-SC and 55% Prev-MC (Chi-square P < 0.05). There were no differences between groups in operative time (overall 210 ± 5 minutes), length of hospital stay (overall 4.7 ± 0.2 days), or 30-day readmissions (overall 7%). During mean follow-up of 66.8 ± 3.4 months (range 12 - 132 months), there were no differences between groups in the percent improvement in DASH score (overall mean decrease 33 ± 2%, preoperative to follow-up t-test P < 0.01) or in patient-reported outcomes (overall excellent 10%, good 36%, fair 43%, and poor 11%).
Conclusions: Anatomically-complete thoracic outlet decompression for recurrent NTOS can be safely and effectively accomplished by SC reoperation, regardless of the type of previous procedure(s) and despite significant preoperative disability. Residual scalene muscle and first rib remnants are more frequently encountered after previous TA operations than after SC or multiple/combined operations. Long-term outcomes show that SC reoperation can achieve significant symptom reduction and functional improvement for nearly 90% of patients with recurrent NTOS.
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