What surgical techniques are used for TOS treatment?
Surgery for thoracic outlet syndrome aims to relieve the pressure on nerves and blood vessels and is called thoracic outlet decompression (TOD). Several surgical techniques are used for TOD. They can be divided into two main groups: with and without rib removal.
TOD without rib removal is performed from the front of the neck above the clavicle and is called anterior supraclavicular neurolysis or neuroplasty. Neurolysis is procedure when surgeon releases bands, muscles, lingaments stretching or compressing the nerves. This procedure is relatively simple and has less complications associated with the first rib resection. Endoscopic brachial plexus neurolysis and myotomy (muscle cutting) is new procedure where the procedure is performed through small insicions and endoscope rather than open incision.
Removal of the first can be performed through anterior (supraclavicular, infraclavicular) or lateral (transaxillary) approach. Accessory ribs sprouting out from the C7 vertebra are very difficult to remove through transaxillary route.
Endoscopic and robotic approaches are performed from chest cavity by deflating the lung and reaching the the first rib from below.
All of first rib removal surgeries suffer from the main handicap – inability to remove the deepest portion of the first rib attached to the spine. However, that part of the first rib is of utmost importance since it is in direct contact with the nerves and the most frequent source of compression.
What are the factors associated with success of TOS surgery?
The most important factor associated with a favorable outcome after thoracic outlet decompression is the extent of the first rib resection. In this context, operations without removing the first rib have the lowest success rate. Patients may get worse after surgery because of nerve manipulation and scar tissue formation. Contrary, removing the first rib works much better. However, complete resection of the first rib is practically impossible using conventional surgical methods. Usually, only the middle portion of the first rib can be removed, and bone stumps attached to the spine and sternum remain after surgery and are the main causes of recurrence. The patients may feel initial improvements but later symptoms return. The rate of recurrence is increasing with time reaching nearly 60-70% after 5-10 years.
The second most important foctor is the release of soft tissue bands that compress or stretch brachial plexus, specifically – C8/T1/inferior trunk complex. This part of the brachial plexus is deeply hidden and very hard to reach with conventional methods. Yet PURED approach allows wide and safe access to this part of the brachial plexus. This way the surgeon may safely decompress the deepest sector of the brachial plexus and ensure total recovery.
The third factor contributing to long term success of TOS surgery is growth of fibrotic tissue. The human body has an amazing ability to heal even most complex wounds. It does so by filling the empthy space with fibrotic tissue which later rectracts. This fibrosis is a double edged sword in case of TOS surgery. On one hand it ensures wound closure and healing. On the other hand fibrotic tissue sticks to the exposed nerves and may later compress and stretch them. Therefore, decreasing postoperative fibrosis is essential for long term success. Fibrosis is particularly problematic in cases where insufficient rib resection is performed. It may anchor the nerves to remaining nearby bones and significantly restrict physiological motion and tension. As a result severe, debilitating chronic neuropathic pain may evolve. This pain may lead to chronic regional pain syndrome (CRPS) – a very debilitating chronic pain syndrome which very difficult to treat.
What is TOS dilemma?
TOS dilemma states that safety and efficacy of thoracic outlet surgery cannot be simultaneously accomplished. The surgeon must compromise one for the sake of the other. The efficacy of TOD surgery is directly related to the aggressiveness of the first rib resection. Aggressive approach leads to high surgical morbidity compromising the safety. As a matter of fact, each surgeon should decide for himself on what point of this safety/efficacy spectrum he is. This leads to significant variability of first rib resections among different surgeons. The thoracic outlet dilemma was the single most important unsolved problem in the field of TOS surgery. It was solved in 2015 by Dr. Aghayev’s posterior technique.
What are the reasons for alternative surgical technique
Thoracic outlet syndrome remains one of the most under diagnosed and under treated diseases. More often than not, surgical treatment of TOS is unsuccessful. Whatever surgical technique is employed, first rib removal is almost always incomplete leading either to suboptimal results or persistence/recurrence. It is hard to believe that with astonishing modern medical achievements complete first rib removal is still a problem. Nevertheless, this is the current state with thoracic outlet syndrome. Significant number of surgically treated patients do not benefit from surgery, others get worse. PURED was introduces to solve this problem and help suffering patients.
Historical precedents of posterior approach
In 1962 Clagett described the posterior approach for the first rib removal and decompression of the neurovascular bundle1 From a modern point of view the approach is not completely posterior rather posterolateral. In 1970’s the Clagett’s initial approach was modified into “subscapular approach”. Despite promising outcomes the posterior technique had a major drawback – it required cutting scapular muscles in order to move it laterally for accessing the first rib. This led to scapular instability and loss of arm function. Eventually, the posterior technique was abandoned in its initial form. It was used only to remove remnants of the first rib for recurrent cases.
PURED PROCEDURE
PURED is an acronym and stands for Posterior Upper Rib Excision and Decompression. It was introduced in 2015 by Dr. Aghayev – a unique, posterior, minimally invasive technique that allows complete removal of the first/accessory ribs and total decompression of neurovascular bundle. 2
The revolutionary innovation combined modern surgical tools with precise anatomical knowledge. This enables total first rib resection without even touching the scapula. An intermuscular technique is used nowadays which allows reaching and removing the first rib without cutting any muscles. This modification allowed PURED technique to address all TOS forms and provide standard, consistent benefits. Another important advantage includes access to the brachial plexus nerves at their exit from the spine. This area which wasn’t accessible with old methods is the primary site of nerve impingiment. Therefore, it is now possible to eliminate the primary cause of TOS by using PURED technique.
Surgical technique
PURED procedure is performed in several steps or phases. These steps should be fully and flawlessly implemented to ensure the best results. These phases include access, bone removal, neuro-vasculolysis and fat tissue filling.
Access
The procedure is performed from the back with approximately 4 cm (less than 2 inch) skin incision between the scapula and the midline. Underneath the skin there is a natural corridor between upper back muscles leading to the first rib. This inverted pyramidal space with triangular base was discovered by Dr. Aghayev in 2017. 3 It is filled with loose fat tissue and is easy to pass through. This way surgeon can access the thoracic outlet area without sacrificing upper back muscles. The structures of interest like spine, first rib, accessory rib, brachial plexus, subclavian artery, vein, scalene muscles can be widely exposed.
Bone removal
The first and accessory cervical ribs are covered by muscles. Additionally, the first rib is partially hidden under the transverse process of the T1 vertebra. For total removal the surgeon must slowly and carefully remove all bones and muscles covering the ribs to expose them. Only after having full visual control, ribs are resected. The good news is that this part of surgery does not require exposure and manipulation of the brachial plexus. The nerves are very delicate so it is wise to leave them under the “blanket of muscles” until bone removal is finished. Subclavian artery lies under this blanket and well protected. Only the subclavian vein is exposed during this part due to its relatively large size and immediate proximity to the first rib. The vein however is very mobile and tolerates retraction very well. The first rib is removed up to all its joints which connect it to the T1 vertebra and sternum. By visually confirming all joint surfaces surgeon validates completeness of the bone removal and ensures that nothing of the rib is left.
Neuro-vasculolysis
First and accessory rib removal provides significant decompression of the subclavian artery, vein and brachial plexus. But soft tissue compression may remain even after complete bone removal. Fortunately, PURED approach allows broad access to the entire neuro-vascular bundle. First the middle scalene muscle is gradually removed exposing the brachial plexus. During this step any abnormal fibrotic, muscular and vascular bands are carefully dissected and cut. Thankfully, first rib resection provides ample space for nerve and vessel manipulation. After finishing with brachial plexus subclavian artery and vein are also freed up from fibromuscular bands. At the end of this phase surgeon has an unobscured view of the entire neuro-vascular bundle.
Fat tissue filling
Wide exposure of the nerves and vessels ensures complete release from compression. Unfortunately broad access invites extensive scar tissue formation. Unlike other surgeries where postoperative fibrosis is not a big problem, thoracic outlet decompression is different. Fibrosis sticks to the brachial plexus and may result in chronic, debilitating neuropathic pain. This type of pain is hard to treat. Luckily PURED procedure provides solution to this problem as well. A small (5 mm) incision is made in the lower back area and subcutaneous fat tissue is harvested by liposuction technique. This fat tissue is then injected into the surgical cavity until it is full. This way scar tissue cannot fill the void space created by bone and muscle removal. Soft and supple fat provides best environment for delicate nerves and vessels and maintains their mobility.
Postoperative care
Following the surgery the patients are transferred to their room. There is no need for intensive care unit (ICU) stay. The patients are mobilized as early as possible. Patients use incentive spirometry to rapidly regain full lung capacity. No antibiotics are given and no infection cases have ever occurred with PURED procedure. Pain is moderate, no narcotic medications are given. Usual hospital stay is 2-3 days. Usually the patients resume normal lifestyle within one month. Most patients with bilateral symptoms can be treated with in one session.
Advantages
- The first and accessory rib removal is easy and safe since there are no overlaying nerves and vessels.
- The brachial plexus is shallow posteriorly, allowing the surgeon to decompress it more effectively Additionally, subclavian vessels are deeper into the brachial plexus and do not interfere with manipulation. Therefore, decompression is easy, safe, and effective.
- The PURED procedure can be applied to all TOS forms. Neurogenic, arteriral and venous versions as well as their combinations can be treated with a single standard technique.
- The most important advantage of the PURED technique is the absence of recurrence due to total resection of the accessory and first ribs.
- The PURED technique provides a very high level of safety compared to other approaches due to minimal vascular and nerve manipulation.
- Dr. Aghayev has been performing this procedure for over ten years with more than 200 patients treated. 4 There was no single complication and all patients improved. Some patients had surgery before via the anterior or transaxillary approach. Even in these recurrent cases PURED technique cured all symptoms.
References
- Clagett OT. Research and prosearch. J Thorac Cardiovasc Surg. 1962;44:153-166[↩]
- Aghayev K, Ciklatekerlio O. Posterior Upper Rib Excision for Neurogenic Thoracic Outlet Syndrome—Feasibility and Early Outcomes. Oper Neurosurg (Hagerstown). 2018;14(5): 532-537. https://doi.org/10.1093/ons/opx143[↩]
- Akaslan I, Ertas A, Uzel M, Ozdol C, Aghayev K. Surgical Anatomy of the Posterior Intermuscular Approach to the Brachial Plexus. Hand (N Y). 2021;16(6): 759-764. https://doi.org/10.1177/1558944719895619[↩]
- Aghayev K. Safety and Efficacy of Posterior Upper Rib Excision and Decompression Technique for Surgical Treatment of Neurogenic Thoracic Outlet Syndrome. World Neurosurg. 2023;180: e739-e748. https://doi.org/10.1016/j.wneu.2023.10.017[↩]
