The transaxillary approach has its advantages
I began my vascular fellowship at UCLA on July 1, 1986 – the previous day I was a chief surgery resident running a VA general surgery service where my last emergency case that evening was an abdominal peroneal resection for perforated rectal cancer! I was delighted to begin my fellowship, and learned that on Tuesdays I would be operating with Herb Machleder, MD – the expert on thoracic outlet syndrome (TOS) who perfected the transaxillary approach. I remembered his service from when I was an intern holding the patient arm up by cradling it my arms while he and the fellow removed the rib and identified each structure—subclavius tendon, subclavian vein, anterior scalene muscle, subclavian artery brachial plexus and any other abnormal band or structure present. The rib was removed in entirety to ensure an excellent outcome and to prevent any possibility of recurrence from scarring to the brachial plexus to a portion of retained rib. Dr. Machleder then went on to design a rib retractor to better support the arm and afford superb visibility.
As I began my career, I included transaxillary first rib resection as part of my practice for all forms of TOS, except when we needed to replace the subclavian artery because of an aneurysm or thrombosis. In those instances, we would employ the supraclavicular approach with an infraclavicular incision when necessary. In my 5 years as chief of the division of vascular surgery at UCLA (1998-2003), we saw many patients with TOS thanks to the legacy and practice of Dr. Machleder. We performed approximately 300 such operations between three of us and saw probably three to four times as many patients in clinic who did not need surgery to treat their TOS or other conditions.
When I arrived at Johns Hopkins as department chair in 2003, a robust thoracic outlet program did not exist there, so we began one. By the time I left in 2014, we were seeing 5-7 new patients per week and were operating on 125 per year, of which half were neurogenic. Ying Wei Lum, MD, and Maggie Arnold, MD, are continuing that practice at Johns Hopkins today.
The most important point about the “approach” for neurogenic thoracic outlet syndrome is whether or not you should operate. At Johns Hopkins, we only operated on about a third of those who presented to us with neurogenic symptoms, as 60%-70% will get better with a thoracic outlet–focused physical therapy regimen. We developed a protocol for this, which we actually handed to the patients as the prescription as they came from all over for our opinion on their conditions. We are doing the same at UC Davis.
We have published a great deal about patients who do not do as well with the surgical approach to neurogenic TOS. These patients include those over the age of 40 and those who have had symptoms for more than 10 years, as they tend to be quite debilitated and never quite recover fully from the operation.1 A scalene block with lidocaine can predict success in patients with the operation, and I use it in older patients or those with multiple complaints.2 At UC Davis, our pain service can perform the block with ultrasound guidance, which is easier for the patient.
Other patients who do not do well with the surgical approach to neurogenic TOS include those with other comorbidities such as cervical spine disease and shoulder abnormalities or injuries, as well as those with a severe dependence on pain medication due to such medical issues as complex pain syndrome or myofasciitis caused by comorbid diseases.3
These patients cannot adequately perform the requisite postoperative physical therapy to completely improve, and some can take up to a year to get range of motion and strength back. We also found that patients who smoke get recurrent disease due to scarring.
At both UC Davis and Johns Hopkins, we created a YouTube video for patients to educate them on the procedure and expected results. The need for postoperative physical therapy should be emphasized in all patients. Some require more therapy than others, which means taking time off from work to focus on the therapy and not performing other activities until the pain and discomfort are gone and strength is back. In another study we performed, we found that if patients did improve the first year, they were more likely to stay symptom free over many years.
While we were doing a transaxillary rib resection case at UC Davis, my team, which includes my partner Misty Humphries, MD, created a list of the top 10 reasons that the transaxillary approach is preferred for neurogenic thoracic outlet syndrome: