Arthroscopy-assisted First Rib Resection and Brachial Plexus Neurolysis for Thoracic Outlet Syndrome

doi:10.21203/rs.3.rs-294089/v1

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Research Article

Arthroscopy-assisted First Rib Resection and Brachial Plexus Neurolysis for Thoracic Outlet Syndrome

https://doi.org/10.21203/rs.3.rs-294089/v1

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posted 17 Mar, 2021

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The present study included 27 consecutive patients (30 limbs) undergoing arthroscopy-assisted transaxillary first rib resection and brachial plexus neurolysis for thoracic outlet syndrome (TOS). To improve visualization, we changed the intraoperative limb position in three stages. We assessed the intraoperative parameters, including the scalene interval width between the anterior and middle interscalene muscles (interscalene base), blood loss, operation time, preoperative and postoperative QuickDASH, patient satisfaction, and complications. The mean intraoperatively measured interscalene base width was 6.2 mm. Appropriate visualization could be obtained at zero-position in the late phase. Intraoperative blood loss and operation time were significantly less in the late phase (p < 0.001). The QuickDASH score was significantly improved (42 before surgery vs. 9 at final follow-up, p < 0.001), especially in athletes relative to non-athletes (0.2 vs 14, p < 0.001). The outcome was excellent in 43.3% of cases, good in 43.3%, fair in 13.3%, and poor in none. The present approach achieved complete relief in 43% of cases overall (91% in athletes and 16% in non-athletes). Pneumothorax was present at the early phase in 3.3%. There were no other complications and no recurrences. Arthroscopic surgery is useful for TOS, especially in athletes.

Scientific Communication

Health Economics & Outcomes Research

Cellular & Molecular Neuroscience

thoracic outlet syndrome (TOS)

visualization

middle interscalene muscles

blood loss

operation time

preoperative and postoperative QuickDASH

patient satisfaction

Surgical treatment for thoracic outlet syndrome (TOS) associated with a cervical rib was first described by Coote in 1861¹. Morley described that brachial pressure neuritis occurred in the absence of a cervical rib, and that resection of a normal rib yielded very satisfactory results². Rogers was first to describe pain in the upper limb due to lesions of the ‘thoracic outlet’ ³. Several surgical treatments for TOS have been reported, including supraclavicular scalenectomy leaving the first rib intact⁴, supraclavicular first rib resection with scalenectomy⁵, transaxillary first rib resection⁶, and endoscopic brachial plexus neurolysis⁷. Transaxillary first rib resection has become the most common procedure for TOS. However, it is usually difficult to obtain satisfactory visualization under direct vision, and it is sometime difficult to control bleeding. Therefore, this procedure is associated with recurrence and complications to some degree^8–12. Endoscopically assisted first rib resection and robotically assisted thoracoscopic first rib resection have reduced the incidence of these complications^13–19.

We hypothesized that an arthroscopically assisted transaxillary approach would be able to improve visualization and allow safe surgery for both vascular and neurogenic TOS, and that the position of the upper limb would be important for transaxillary insertion of the arthroscope. The purpose of the present study was to evaluate the results of arthroscopic transaxillary first rib resection with scalenectomy and brachial plexus neurolysis for TOS in different limb positions.

Indications and imaging.

We performed surgery only for patients with certain objective findings, including blood flow disruption (Video 1), low blood flow (Fig. 1a, affected limb; Fig. 1b, contralateral side), and accelerated blood flow (Fig. 1c, affected limb; Fig. 1d, contralateral side) in the subclavian artery demonstrated using Doppler sonography, narrowing of the interscalene base or costoclavicular space demonstrated using Duplex ultrasonography set at an ABER position or CT, or narrowing of the subclavian artery demonstrated by CT angiography (Fig. 2a, preoperative; Fig. 2b, six days after surgery). The mean blood flow was 83.2 cm/s (range, 48–120 cm/s) at rest and 144.1 cm/s (range, 32–301 cm/s) at an ABER position sitting in a chair demonstrated by Doppler sonography (Table 1). The mean interscalene base width was 8.7 mm (range, 5.1–16.3 mm) at rest and 8.1 mm (range, 0-14.7 mm) at an ABER position sitting in a chair demonstrated by Duplex ultrasonography (Table 1). The mean costoclavicular space demonstrated by Duplex ultrasonography was 9.6 mm (range, 4.7–13.1 mm) at an ABER position sitting on a chair and the mean costoclavicular space demonstrated by CT was 11.3 mm (range, 6.2–18.1 mm) with the shoulder at full abduction (Table 1).

Table 1

Patient Demographics, perioperative measurements
				Blood Loss	Operative Time (min)	Intraoperative SIW (mm)	Ultrasonography (mm)
Patients	Gender	Age	Phase	(ml)	Operative Time (min)	Intraoperative SIW (mm)	SIW RP	SIW ABER	CCS RP	CCS ABER	AS Rest	CS Rest	AS ABER	CS ABER	CCS
1	Male	17	1	126	307	NA	NA	NA	NA	NA	69	126	220	131	9.1
2	Female	34	1	9	166	NA	NA	NA	NA	NA	60	237	59	267	13
3	Male	17	1	7	260	NA	NA	NA	NA	NA	120	124	139	139	16.7
4	Male	15	2	89	165	NA	NA	NA	NA	NA	107	103	107	109	13.6
5	Male	29	2	101	272	2	12	11	21	18	83	73	263	321	16.2
6	Female	50	2	17	183	5	6.9	7.8	9.1	8.6	72	100	62	279	7.5
7	Female	45	2	51	174	8	8.4	7.8	10.6	7.8	72	40	73	41	18.1
8	Female	45	2	25	170	8	10.7	9	10.1	9.9	48	64	45	42	7.8
9	Female	29	2	11	148	3	5.3	8.3	14	11	79	71	125	104	6.1
10	Male	16	2	71	130	6	6.8	8.2	6.9	6.9	113	89	164	231	15.6
11	Female	29	2	10	86	8	5.1	5.2	11.4	11	120	103	127	115	8.3
12	Female	44	2	10	120	6	14.9	14.7	5.9	5.1	71.8	53.3	120.4	67.2	7.1
13	Female	29	2	6	120	6	16.3	14.6	14.1	13.1	70	89	79	158	16
14	Male	16	2	25	135	6	9.8	8.7	12.7	8.4	127	130	295	183	12.3
15	Male	22	2	20	156	3	8.3	6	10.8	8.9	68	70	314	251	6.2
16	Male	35	2	10	122	6	6.5	7.1	11.8	9.9	66	53	42	67	8.5
17	Female	37	2	18	160	8	8.4	7.4	12.5	13.1	69.5	73.1	86.7	75.6	8.3
18	Male	22	2	26	140	10	6.7	5.4	6.7	4.7	88	105	32	126	9.3
19	Male	22	3	20	114	4	7.4	0	7.3	6.4	70	67	251	314	8.6
20	Male	35	3	12	90	6	7.2	6.9	15.1	14.3	53	66	67	42	8.1
21	Female	30	3	8	96	6	13.6	14	12.3	11.9	89	70	158	79	15.4
22	Female	30	3	3	60	5	5.1	5.3	7.3	6.5	95	92	99	114	11.1
23	Female	17	3	5	70	2	7.4	6.2	5.9	3.5	92	81	227	148	7.3
24	Female	44	3	18	88	12	7.3	7.8	13.4	11.9	68	66	66	61	13.2
25	Male	17	3	4	71	3	8.5	7.9	9.9	7.8	103	123	128	164	16.2
26	Male	17	3	16	132	4	9.7	8.6	13.7	12.4	82	103	180	224	13.8
27	Male	17	3	3	78	7	8.3	8.7	12.8	11.4	101	83	301	154	11.3
28	Female	44	3	8	100	8	8.6	8.4	17.9	12.1	55	54	54	56	15
29	Male	22	3	5	62	10	8.5	9	7.8	8.9	90	89	169	108	11
30	Male	17	3	15	84	8	7.3	7.2	9.3	6.8	96	98	270	214	7
Mean		28.1		25.0	135	6.2	8.7	8.1	11.2	9.6	83.2	89.8	144.1	146.1	11.3
SIW, scalene interval width between anterior and middle interscalene muscles
RP, resting position; ABER, shoulder in abduction and external rotation position
CCS, costoclavicular space; NA, not available
AS, affected side; CS, contralateral side; Rest, resting position

Surgical procedure and intraoperative measurements.

Appropriate visualization could not be obtained simply by inserting the arthroscope at 150 degrees of limb abduction (Fig. 3a) nor at 90 degrees of limb abduction with the arm pulled upwards (Fig. 3b). Therefore, we needed to improve the visualization using some large retractors. However, better visualization was obtained simply by inserting the arthroscope without any retractors at a subordinate pivotal position²⁰ where the deltoid, the supraspinatus and the infraspinatus were relaxed (Fig. 3c, Video 2, 3). Appropriate visualization was also obtained by applying antifog to the arthroscope and attaching suction to the side of the arthroscope (Fig. 4), thus significantly decreasing the amount of intraoperative blood pooling. The mean intraoperative blood loss was 25 mL (range, 3-126 mL): 47 mL (range, 7-126 mL) in the early phase, 33 mL (range 6-101 mL) in the middle phase, and 10 mL (range, 3–20 mL) in the late phase (Table 1). Intraoperative blood loss was significantly lower in the late phase (p < 0.001). The mean intraoperative measured width of the interscalene base was 6.15 mm (range, 2–12 mm). The mean operation time was 135 min (range, 60–307 min), being 244 min (range, 166–307 min) in the early phase, 152 min (range, 86–272 min) in the middle phase, and 87 min (range, 60–132 min) in the late phase (Table 1). Operation time was also significantly shorter in the late phase (p < 0.001).

Clinical assessments.

The mean Quick Disability of the Arm, Shoulder and Hand (QuickDASH) score was 42 (range, 11–96) before surgery and 9 (range, 0–48) at final follow-up (p < 0.001), demonstrating a significant improvement (Table 2, 3). The mean QuickDASH score at final follow-up was 0.2 (range, 0–2) in athletes and 14 (range, 0–48) in non-athletes (Table 3). The QuickDASH score was significantly better in athletes (p < 0.001, Table 3). All of the patients were satisfied with their surgical outcomes and were happy with the improvement seen in their limbs. The rating was excellent in 13 patients (43.3%), good in 13 (43.3%), fair in 4 (13.3%), and poor in none (Table 2). Complete relief with the present methods was achieved in 43% of the patients (91% in athletes and 16% in non-athletes). There was one case (3.3%) of slight parietal pleura damage in the early phase with no complaint, and healing was achieved without any additional treatment. There were no other complications and no cases of recurrence.

Table 2

Clinical Assessment
		Preoperative QuickDASH		Postoperative QuickDASH		Differences of QuickDASH		Patient Satisfaction
Patients	Sports	D/S	Sports	D/S	Sports	D/S	Sports	Patient Satisfaction
1	Baseball	27	100	0	0	27	100	Excellent
2		19		0		19		Excellent
3	Baseball	30	75	0	0	30	75	Excellent
4	Baseball	68	75	0	0	68	75	Excellent
5		27		18		9		Good
6		45		34		11		Good
7		89		11		78		Fair
8		52		5		47		Good
9		95		48		47		Fair
10	Baseball	32	75	2	0	30	75	Good
11		84		11		73		Good
12		66		25		41		Good
13		75		16		59		Good
14	Baseball	27	100	0	13	27	87	Good
15		11		0		11		Excellent
16		64		9		55		Good
17		23		7		16		Good
18	Baseball	30	50	0	0	30	50	Excellent
19		11		0		11		Excellent
20		89		9		80		Good
21		50		16		34		Good
22		52		23		29		Good
23	FH	18	100	0	0	18	100	Excellent
24		27		11		16		Fair
25	Baseball	30	88	0	0	30	88	Excellent
26	Baseball	27	63	0	0	27	63	Excellent
27	Baseball	16	88	0	0	16	88	Excellent
28		11		0		11		Excellent
29		20		18		2		Fair
30	Baseball	32	75	0	0	32	75	Excellent
Mean		42	81	9	1	33	80
QuickDASH, Quick Disability of the Arm, Shoulder and Hand ; D/S, disability/symptom FH, field hockey

Table 3

Comparison of Perioperative QuickDASH Scores between Athlete and Nonathlete
	QuickDASH		p
	Preoperative	Postoperative
Athlete	31 (16–68)	0.2 (0–2)	< 0.001
Nonathlete	48 (11–96)	14 (0–48)	< 0.001
Total	42 (11–96)	9 (0–48)	< 0.001
QuickDASH, Quick Disability of the Arm, Shoulder and Hand

Vascular TOS cases can be diagnosed by Color Doppler and Duplex ultrasonography^21,22 or CT angiography^23–25. We evaluated patients with vascular TOS using similar methods. Blood flow disruption, low blood flow, and accelerated blood flow of the subclavian artery were measured using Doppler sonography in an ABER position. Neurogenic TOS cases can also be diagnosed by Duplex ultrasonography^26,27. In cadaver studies, the mean interscalene base width and mean costoclavicular space have been reported to be 10.7 mm and 13.5 mm, respectively²⁸. The mean costoclavicular space measured by CT was 12.5 mm²⁹. Preoperative and intraoperative measures of the interscalene base can predict disorders due to scalene triangular stenosis. In the presence of clinical TOS, the scalene muscles compress the structures of the brachial plexus in the thoracic outlet between the anterior and middle scalene muscles. Therefore, both scalenectomy and first rib resection provide significant functional improvements in patients with TOS.

Arthroscopic surgery requires appropriate visualization, especially when inserting an arthroscope in a place other than a joint. Therefore, we changed the upper arm position in three phases. Better visualization was obtained at the subordinate pivotal position²⁰/zero-position³⁰. The relationship between the neurovascular bundle and the scalene muscles could be observed clearly using an arthroscope in the zero-position. Furthermore, arthroscopic neurolysis was possible when the brachial plexus and subclavian artery were adherent. Arthroscopically assisted surgery allowed decompression for both vascular and neurogenic TOS.

There are three major procedures for TOS in the absence of a cervical rib: transaxillary first rib resection^8,31−33, supraclavicular first rib resection^{2,5,11,34−36}, and supraclavicular release of the anterior and middle scalene muscles leaving the first rib intact^37–39. Statistically there is no significant difference in outcome between the three procedures, fair results being reported in 4–8% of each group¹¹. A systematic literature search revealed that both supraclavicular scalenectomy and transaxillary first rib resection had a high probability of success¹². In the present study, arthroscopically assisted surgery achieved some degree of improvement in all patients. The mean improvement of QuickDASH was 33, and the complete relief was obtained 43% of the patients. TOS sometimes occurs in throwing athletes^40,41. Athletes show better improvement than non-athletes after first rib resection and scalenectomy⁴². Here, complete relief was observed significantly more often in athletes than in non-athletes (91% vs 16%).

Transaxillary first rib resection has a higher incidence of complications than supraclavicular scalenectomy, being 22.5% and 12.6% respectively¹². Among 594 cases of TOS treated by transaxillary first rib resection, there were 138 (23%) cases of intraoperative pneumothorax⁸. In the present study, intraoperative pneumothorax occurred in only one case (3.3%) and no other complications or recurrences were observed after arthroscopic surgery. Ohtsuka et al. have reported thoracoscopic first rib resection⁴³. However, as this procedure poses a significant potential risk to the neurovascular bundle, modified techniques with appropriate instrumentation have been developed^16,18. Furthermore, endoscopically assisted transaxiallary first rib resection using a 10-mm endoscope has resulted in a lower incidence of complications^13,14. In the present study, arthroscopically assisted transaxillary first rib resection and brachial plexus neurolysis using a 4-mm arthroscope also achieved good results with a lower incidence of complications.

The present study had several limitations. First, it was based on a retrospective review with a small number of patients and lacked a control group. Second, most cases of TOS can be cured by conservative therapy. Therefore, there are relatively few cases requiring surgery in our department, and for this reason we accepted TOS patients from other institutions who had not responded to conservative therapy and needed surgery. Because the sample size was limited, a controlled trial would have taken much more time, delaying the publication of the preliminary outcomes. Arthroscopically assisted transaxillary first rib resection and brachial plexus neurolysis allowed us to obtain satisfactory results and was a safe procedure for TOS. In particular, athletes showed significantly better improvement than non-athletes. Third, the diagnosis of TOS is well known to be controversial^44,45. In the present study we excluded one patient with ‘true neurogenic TOS’ ^22,46,47 associated with a cervical rib. We diagnosed TOS using Doppler sonography adopting an ABER method or CT angiography.

Study design.

Twenty-eight consecutive patients (32 limbs) with TOS who underwent surgery in our department between April 2016 and February 2020 were evaluated. We excluded one patient (2 limbs) with ‘true neurogenic TOS’ on the basis of Gilliatt-Sumner hand^22,46,47 associated with bilateral cervical ribs, which were excised by the supraclavicular approach. Among the remaining 27 patients, 30 limbs were included in the present study. There were 14 males and 13 females, and the mean age at surgery was 28.1 years (range, 15–50 years).

Diagnosis.

The diagnosis of TOS is controversial^44,45, and no specific set of diagnostic criteria has yet been established⁴⁸. We diagnosed patients as having TOS on the basis of symptomatic presentation, physical examination maneuvers including the Roos test⁴⁹, Wright test⁵⁰ and Moley test², and lack of any evidence of a more likely cause. Patients with traumatic TOS were excluded. Color Doppler and Duplex ultrasonography are useful diagnostic modalities in this context^21,22. The measures assessed included blood flow disruption, low blood flow, and accelerated blood flow in the subclavian artery demonstrated by Doppler sonography, the scalene interval width between the anterior and middle interscalene muscles (interscalene base)²⁸, and the costoclavicular space demonstrated by Duplex ultrasonography^26,27 in a resting position with the shoulder in abduction and in the external rotation (ABER) position sitting on a chair (Fig. 5) by a medical technologist (T.K.). Furthermore, enhanced computed tomography (CT) was performed with the shoulder in full abduction to confirm the presence of stenosis of the subclavian artery^23–25 and the costoclavicular space²⁹. If peripheral neuropathy such as ulnar and median neuropathy could not be ruled out, nerve conduction studies were also performed.

Surgical technique.

The patient was placed in a lateral position with the arm elevated to expose the axilla using a limb positioner (SPIDER2, Smith & Nephew, Memphis, TN) for the upper extremity and operated on under general anesthesia. The upper limb position was set at 150 degrees of abduction in the early phase (n = 3, Fig. 3a), 90 degrees of abduction with the arm pulled upwards according to Roos³³ in the middle phase (n = 15, Fig. 3b), and in the subordinate pivotal position²⁰/zero-position³⁰ in the late phase (n = 12, Fig. 3c). At the beginning, it was difficult to obtain appropriate visualization. Therefore, we changed the position in three stages to improve visualization (Videos 2, 3).

A transverse 4-cm skin incision was made over the third rib between the pectoralis major and the latissimus dorsi muscles at the axillary hairline level (Fig. 3d). Careful dissection was performed to allow confirmation of subclavian artery pulsation with a finger. An arthroscopic incision was made more superior and posterior at the third rib level (Fig. 3d). We used a 4-0-mm 30-degree arthroscope, detached both the anterior and middle inter-scalene muscles from the first rib, excised the first rib piecemeal using bone cutting rongeurs, and neurolysis of the brachial plexus was performed with arthroscopic assistance (Fig. 6, Video 4).

Postoperative care.

Range of motion exercise for shoulder abduction up to 90 degrees was allowed immediately after surgery, and unlimited shoulder motion was allowed after four weeks. The patients returned to full activities, such as sports, between two and three months after surgery.

Evaluation of clinical data and definitions of outcome variables.

A comprehensive review of medical records was conducted by one observer (H.S.). Demographic and surgical data collected included the following: securing visualization in each upper limb position; intraoperative measurement of the interscalene base; intraoperative blood loss; operation time; preoperative and postoperative QuickDASH; patient satisfaction; and complications at a mean of 25.6 months (range, 12–56 months) after surgery. Patient satisfaction was divided into four categories according to Derkash et al.⁵¹: excellent, complete relief; good, almost complete relief; fair, partial relief; poor, no improvement. We compared the clinical results among these patients according to whether they were athletes or not.

Statistical analysis.

The QuickDASH was compared using Wilcoxon test and Fisher’s exact test, while intraoperative blood loss and operation time were compared using Kruskal-Wallis test. Differences at P < 0.05 were regarded as statistically significant. All statistical analyses were performed with the EZR software program (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria, version 3.6.3)⁵².

Ethical statements.

This study was approved by the ethics committee of Yamagata University (No. 2020-358), and was conducted in accordance with the ethical standards described in the latest revision of the Declaration of Helsinki.

Patient consent for participation and publication.

Informed consent for patient participation and publication was received in the form of an opt-out in-hospital notice.

Data availability

All data relevant to the study are included in the article.

Acknowledgement

The authors thank Dr. Kozo Furushima at Keiyu Orthopaedic Hospital, for technical assistance.

Author contributions

H.S. performed all surgery and wrote the main manuscript. R.H. aided with statistical analysis and fitting of equations. T.N. researched the literature and conceived the study. Y.N. aided with statistical analysis and fitting of equations. J.S. assisted surgery. M.M. researched the literature and conceived the study. T.U. assisted surgery. T.K. performed Doppler sonography and Duplex ultrasonography. M.T. wrote the main manuscript. All authors reviewed and edited the manuscript and approved the final version.

Funding

None to report.

Competing interests

The authors have no competing interests to declare.

Additional information

Correspondence and requests for materials should be addressed to H.S.

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No competing interests reported.

Video1.wmv
Video 1. Blood flow disruption demonstrated by Doppler sonography. The subclavian artery flow is disrupted when the shoulder is in abduction and external rotation (ABER).
Video2.wmv
Video 2. Subordinate pivotal position. The deltoid, the supraspinatus and the infraspinatus are most relaxed at the subordinate pivotal position compared with the situation at 150 degrees of limb abduction or 90 degrees of limb abduction with the arm pulled upwards.
Video3.m2ts
Video 3. Arthroscopy. Appropriate visualization can be obtained simply by inserting the arthroscope at the subordinate pivotal position/zero-position.
Video4.wmv
Video 4. Surgical technique. Both the anterior and middle inter-scalene muscles are detached from the first rib. The first rib is excised piecemeal using a bone cutting rongeur, and neurolysis of the brachial plexus is performed.

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Arthroscopy-assisted First Rib Resection and Brachial Plexus Neurolysis for Thoracic Outlet Syndrome

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Abstract

Figures

Introduction

Results

Indications and imaging.

Surgical procedure and intraoperative measurements.

Clinical assessments.

Discussion

Limitations

Materials And Methods

Study design.

Diagnosis.

Surgical technique.

Postoperative care.

Evaluation of clinical data and definitions of outcome variables.

Statistical analysis.

Declarations

Ethical statements.

Patient consent for participation and publication.

Data availability

Acknowledgement

Author contributions

Funding

Competing interests

Additional information

References

Competing Interests

Supplementary Files

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