Available online 26 January 2024

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Surgical decompression of the thoracic outlet along with treatment of the involved nerve or vessel is the accepted treatment modality when indicated. While neurogenic thoracic outlet syndrome (nTOS) is often operated via the axillary approach and venous TOS (vTOS) via the paraclavicular approach, arterial thoracic syndrome is almost always operated via the supraclavicular approach. The supraclavicular approach provides excellent access to the artery, brachial plexus, phrenic nerve and the cervical and/or first ribs along with any bony or fibrous or muscular abnormality that may be causing compression on the neurovascular structures. Even for nTOS, where the axillary approach offers good cosmesis, the supraclavicular approach helps adequate decompression while preserving the first rib. This approach may also be sufficient for thin patients with vTOS. For aTOS, a supraclavicular incision usually suffices for excision of bony abnormality and repair of subclavian artery.

Section snippetsHistorical Aspects

In 1818, Astley-Cooper described upper limb ischemia following subclavian artery compression due to an exostosis that was possibly a cervical rib1. Forty years later, Coote2 performed the first cervical rib resection for aTOS. Anterior scalenotomy was described Adson and Coffey3 in 1927 and the phrase “Thoracic Outlet Syndrome” (TOS) was introduced by Peet4 in 1956. In 1984 Qvarfordt5 reported the combined use of supraclavicular and trans-axillary approach since the latter resulted in

Why a Supraclavicular approach to TOS

The essential principles of successful treatment of TOS include decompression and revascularization in aTOS and decompression and neurolysis in nTOS. In patients with vTOS, acute thrombus may be treated with thrombolysis and surgery is required only for decompression. In chronic cases, direct venous surgery may be required. The choice of surgical approach for thoracic outlet decompression is often a point of debate with individual surgeons having their own preferences. nTOS may be operated

The surgical technique

The details of supraclavicular approach have been described earlier, mainly with reference to scalenectomy and resection of first rib12,13. The following is the description of how we perform this surgery.

Anaesthesia and Patient position

The surgery is performed under general anaesthesia with the endotracheal tube positioned in the opposite corner of the mouth. The patient is placed supine with a roll placed beneath the shoulders, the neck extended and rotated to the opposite side and the head resting on a ring. (Figure 1) A short roll placed under the neck can provide support during the surgery. The neck, upper chest and upper limb are prepped and draped with free draping of the upper limb which is made to lie comfortably

Neurolysis

In patients with nTOS, especially those requiring re-operation, there may be scarring around the brachial plexus as a result of previous injury, inflammation and healing. This perineural fibrous tissue can cause fixation and irritation of the brachial plexus resulting in residual neurogenic symptoms. This scar tissue should be very meticulously removed from around the brachial plexus roots and cords using fine scissors. The brachial plexus may be wrapped in polylactide film to reduce the risk

Cervical sympathectomy

This may be useful in patients with ischemia / gangrene of digits when distal revascularization is inadequate19,25 and in nTOS patients with complex regional pain syndrome. The surgery is relatively easy after excision of the culprit rib. Sibson's fascia and the pleura is bluntly stripped from the posterior chest will with blunt finger dissection. The sympathetic chain can be seen and felt over the neck of the first rib and on the heads of the lower ribs. Avoid injury to the first intercostal

Closure of the Incision

It is important to take time to achieve good haemostasis and ensure proper counts so that no gauze pieces are left behind. The wound is now filled normal saline and the anaesthesiologist asked to perform Valsalva manoeuvre on the patient to check for any pleural injury. Pleural injury is indicated by the presence of air bubbles. If this happens, there is no major concern. Avoid trying to repair the pleura because it usually tends to tear even more. If there is a large pleural rent and bleeding

Post-operative care

Post operatively, the patient is nursed in 300 head up position. Radial pulse should be monitored in addition to the standard vitals and saturation. An erect chest x-ray can show the adequacy of rib excision, presence or absence of haemothorax or pneumothorax and the position of the diaphragm that can indicate phrenic nerve injury. The drain can usually be removed in 24-48 hours. The patient should be encouraged to move the neck and upper limb to avoid stiffness and spasm. It is preferable to

Summary

The supraclavicular approach offers perhaps the best access for adequate decompression of thoracic outlet, vascular reconstruction and neurolysis. It also provides an opportunity to preserve the first rib in patients being operated for nTOS or aTOS. It has limitations too when an infraclavicular incision may be required in addition to control the axillary artery in aTOS or control the subclavian vein and resect the anteromedial end of a normal first rib in patients with vTOS

References1.

Cooper A: On exostosis. In: Cooper AP, Travers B, ed. Surgical Essays, 2nd ed. London:Cox and Son,1818, p171.

2.

Coote H: Exostosis of the left transverse process of the seventh cervical vertebra, surrounded by blood vessels and nerves; successful removal. Lancet 1861;1:360-361.

3.

Adson AW, Coffey JR. Cervical rib: a method of anterior approach for relief of symptoms by division of the scalenus anticus. Ann Surg. 1927;85:839–857.

4.

Peet RM, Hendriksen JD, Anderson TP, Martin GM. Thoracic outlet syndrome:

CRediT authorship contribution statement

Prem Chand Gupta: Conceptualization, Methodology, Validation, Writing – original draft, Writing – review & editing. Prajna B Kota: Conceptualization, Methodology, Resources, Writing – review & editing. Vamsikrishna Yerramsetty: Conceptualization, Resources, Writing – original draft, Writing – review & editing. Velladuraichi Boologapandian: Writing – original draft, Writing – review & editing. Viswanath Atreyapurapu: Resources, Writing – review & editing. Pritee Sharma: Methodology, Resources,

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

The authors thank Dr. Laxmi Gupta for the schematic diagrams.

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