NEUROVASCULAR COMPRESSION IN THE THORACIC OUTLET - CHANGING MANAGEMENT OVER 50 YEARS

Summary Background Data During the past five decades, significant impr ovements have been made in the diagnosis and treatment of thoracic out let syndrome (TOS) secondary to sports activities, breast implants, or median sternotomy. Methods, Results, and Conclusions Of more than 15, 000 patients evaluated for TOS, 3914 underwent primary neurovascular d ecompression procedures and 1221 underwent second surgical procedures for recurrent symptoms. Of 2210 consecutive patients, 250 had symptoms of upper plexus compression only (median nerve), 1508 had symptoms of lower plexus compression only (ulnar nerve), and 452 patients had sym ptoms of both. Ulnar and median nerve conduction velocities confirmed the clinical diagnosis. Transaxillary first rib removal alone for neur ovascular decompression relieved both upper and lower plexus symptoms (without a combined transaxillary and supraclavicular approach). There are two reasons for this: most upper compression mechanisms attach to the first rib, and the median nerve is also supplied by C8 and T1 as well as C5, C6, and C7 nerve roots. Axillary subclavian artery aneurys m or occlusion was treated successfully in 240 patients. Dorsal sympat hectomy was performed concomitantly in 71 patients for occlusion or em bolectomy. It was combined with first rib resection in 1974 patients f or sympathetic maintained pain syndrome and causalgia that did not imp rove with conservative therapy. Of 264 patients with effort thrombosis (Paget-Schroetter syndrome), 211 were treated by urokinase thrombolys is and prompt first rib resection with excellent long-term results. Re current TOS symptoms required a second procedure using the posterior a pproach in 1221 patients with brachial plexus neurolysis and dorsal sy mpathectomy. The use of hyaluronic acid significantly reduced recurren t scarring.