Recurrent thoracic outlet syndrome refers to the condition when signs and symptoms of the disease persist or worsen after surgery. There are several reasons for such failure:
There are many conditions that may mimic thoracic outlet syndrome. Cervical disc herniation, shoulder joint problems, and fibromyalgia may produce symptoms that are very difficult to distinguish from TOS. Since TOS is a clinical diagnosis and radiological evaluation is frequently unremarkable, misdiagnosis may happen and could lead to inadequate treatments and failures. Therefore, proper evaluation with a specialist proficient in differential diagnosis is an essential step for success.
It is by far the most common reason for recurrence. There are two reasons for this type of failure: TOS surgery without first rib resection and without adequate rib resection.
This procedure was proposed as the surgical treatment for TOS in the 1930's. It is performed from the supraclavicular approach (from the front slightly above the collar bone). The surgeon exposes subclavian vessels and brachial plexus. Then, the anterior sclane muscle is detached from the rib and partially removed. Initial success combined with low risk, relative technical easiness, and reduced surgical morbidity prompted many surgeons to adopt this procedure. However, follow-up studies showed its ineffectiveness for long-term control of symptoms. Additionally, many follow-up scientific papers comparing rib resection over simple scalenectomy clearly demonstrated the superiority of rib removal. Yet, up to this day, many surgeons are still performing scalenectomy as a sole procedure for TOS treatment.
There is strong scientific evidence indicating that the degree of additional and first rib resection, i.e., extension of bone resection, is the strongest factor influencing long-term success. Typically, patients with TOS undergo surgery either from the front (supraclavicular) or from the armpit (transaxillary). Yet, it is technically difficult and risky for surgeons to remove ribs completely. Therefore, during surgery, deep bone sections remain untouched. These bone parts are the main cause of recurrence after surgery. It has been confirmed that the size of remaining bones correlates with the likelihood and severity of recurrent symptoms. Symptoms may return from months to years following the surgery. In some cases, symptoms are so severe that remaining bony stumps are removed from a different incision in the upper back.
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