Recurrent Thoracic Outlet Syndrome

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:

1. Inadequate surgrical technique. It is by far the most common reason for recurrence.  

• Scalenectomy without rib resection. This procedure was proposed as the surgical treatment for TOS in 1930's. It is performed from the supraclavicular approach (from the front slightly above the collar bone). The surgeon exposes subclavian vesseles 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 promted 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 superiority of rib removal. Yet up to this day many surgeons are still performing scalenectomy as a sole procedure for TOS treatment. 
• Insufficient accessory/first rib removal. There is strong scientific evidence indicating that the degree of additional and first rib resection i.e. extend of bone resection is the strongest factor influencing the long-term success. Typically, patients with TOS undergo surgery either from the front  (supraclaviacular) or from the armpit (transaxillary). Yet it is technically difficult and risky for surgeons to completely remove ribs. Therefore during surgery deep bone sections remain untouched. These bone parts are the main cause for recurrence after surgery. It has been confirmded that the size of remaining bones correlate with 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 boney stumps are removed from a different incision in the upper back.