Neurogenic Thoracic Outlet Syndrome: Outcomes in Rib-Sparing vs. First Rib Resection Techniques
Cristin Coquillard, MD1, Iulianna Taritsa, BA2, Jennifer Bai, MD3, Hannah Soltani, BS3, Rushmin Khazanchi, BA3, Ashley Vavra, MD3 and Jason H Ko, MD, MBA3, 1Northwestern University, Chicago, IL, 2Northwestern University, Boston, IL, 3Northwestern University Feinberg School of Medicine, Chicago, IL
Introduction
Neurogenic thoracic outlet syndrome (nTOS) is a potentially debilitating condition that presents with a constellation of symptoms including paresthesia, pain, and weakness. It is often exacerbated with arm elevation due to compression of the brachial plexus within the thoracic outlet. Surgical treatment has traditionally included resection of the first rib. However, a rib-sparing technique has emerged involving anterior and middle scalenectomy with neurolysis, as well as pectoralis minor release. The purpose of this study was to compare complication rates and functional outcomes between rib resection versus rib-sparing thoracic outlet decompression.
Methods
A single institution retrospective chart review was performed between January 2017 and March 2023. Patients were included who had isolated nTOS and had surgical treatment via first rib resection or rib-sparing thoracic outlet decompression. Patients requiring cervical rib resection and those with vascular or combined TOS were excluded. Pre- and post-operative notes as well as operative reports were reviewed. Data extracted included demographics, symptoms prior to operation, operation performed, peri- and post-operative complications, and functional outcomes. Statistical analysis was performed using Fisher Exact and Welch's two-tailed t-test.
Results
76 patients (34 male, 42 female) with a median age of 37 years old met inclusion criteria. 17 underwent decompression with rib resection versus 59 who underwent a rib sparing technique. The two groups were demographically similar. Complications were seen in 23.5% of the rib resection group versus 5.1% in the rib-sparing group (p=0.0406) (Table). Pleural violation with or without sequelae occurred in 17.6% of rib resection patients vs 1.7% of rib-sparing patients. Motor function was noted to be improved in 31.3% of rib resection patients and 59.3% of rib-sparing patients (p=0.2539). The average improvement in MRC grade across all muscle groups was similar between cohorts (p=0.325).
Conclusions
Thoracic outlet syndrome is a complex disorder with no gold standard treatment. In this study, patients who underwent rib-sparing thoracic outlet decompression had similar functional outcomes to those who underwent first rib resection but had a lower overall complication rate, most notably of complications involving violation of the pleura. Future prospective studies are needed to establish a standard of care for this challenging disorder.
| Total | Rib Resection | Rib Sparing | p value | |
| Rate of All Complications | 9.2% | 23.5% | 5.1% | 0.406 |
| Hematoma (#) | 1 | 0 | 1 | |
| Seroma (#) | 1 | 0 | 1 | |
| Infection (#) | 1 | 1 | 0 | |
| Pleural laceration/pneumothorax/chylothorax | 5.1% | 17.6% | 1.7% | |
| Re-operation | 11.8% | 5.9% | 13.6% | 0.674 |
| Improvement of Motor Function | 52.9% | 31.3% | 59.3% | 0.2539 |
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