Choosing the transaxillary or supraclavicular approach for neurogenic TOS
1. The scar is less noticeable and painful for the patient than the scar in the supraclavicular fossa, allowing the patient to start physical therapy 2 weeks after surgery.
2. The Machleder retractor makes visualization easy and stable, and allows all members of the team to see the anatomy.
3. The brachial plexus does not have to be retracted and is out of harm’s way, so no temporary palsies are seen in the postoperative period.
4. The subclavius tendon can be seen in entirety and the anterior portion of the rib is easy to completely remove.
5. The subclavian vein can be seen in entirety and defines the anterior portion of the dissection.
6. Once the anterior scalenectomy muscle is cut, the subclavian artery naturally retracts cephalad and is no longer near the rib when it is to be removed.
7. The posterior portion of the rib can be completely removed by readjusting the retraction and a second cut can be done safely with either the rib cutter or the first rib rongeur. It is essential to remove the rib posteriorly behind the nerve root so the arm is adducted and the nerve does not come in contact with the remaining rib, as we feel that leads to increased recurrences.
8. Two operating surgeons can address the rib from their side of the table and completely resect the rib, depending on the patient’s soft bony anatomy, by angling the instruments from either side.
9. Even large muscular or obese patients can be safely approached from the axilla utilizing the Machleder retractor and a lighted retractor.
10. The transaxillary approach can be taught through the teaching video we have made and through the ability for both surgeons to see because of the retractor.
Some of my favorite memories as a vascular surgeon were operating on Tuesdays with Dr. Machleder – similar to Tuesdays with Morrie.4 Not only did we remove ribs safely and completely, but he also taught me philosophy of surgery and of life. I hope I am doing the same with my team as we remove ribs now on Thursday – “Thursdays with Freischlag” – at UC Davis.
Dr. Freischlag is vice chancellor for human health sciences and dean of the school of medicine at the University of California, Davis. She had no relevant disclosures.
References
1. J Vasc Surg. 2012;55(5):1370-5.
2. Curr Treat Options Cardiovasc Med. 2009;11(2):176-83.
3. J Vasc Surg. 2012;56(4):1061-7.
Use a supraclavicular approach: My way is best!
The best sense we have of the pathophysiology of neurogenic (NTOS) is that the scalene triangle is “too tight” with regard to what it contains – the brachial plexus and the subclavian artery. Whether this is due to the triangle being too small or the nerves being “too large” (inflammation) is unknown. Supporting the former theory are observations that the anterior scalene muscle is frequently inflamed and/or chronically injured.1 but others have suggested that the first rib is abnormally located or elevated.2 In addition, some have suggested that inflammatory tissue surrounding the plexus contributes to the process, at least for chronic cases.3
Given the fact that at least two of the three parts of the triangle, plus tissue surrounding the plexus itself, have all been implicated in the disease process, why not choose an approach that allows correction of all potential causes? The transaxillary approach has been used for decades for this condition, but can only decompress the base of the triangle (first rib) and, to varying degrees, only part of the anterior scalene. It does not allow thorough exploration of the nerves. The supraclavicular approach (and the supraclavicular half of paraclavicular excision) addresses these concerns. First, the anterior scalene muscle is essentially entirely removed. With proper technique it is completely visible from the scalene tubercle to its origin at the spine. This approach also allows removal of all muscular and associated tissue medially, completely clearing the parietal pleura at the apex of the lung, at least theoretically reducing the chances of scar tissue arising from residual tissue here.
Second, although no research has yet implicated the middle scalene (scalenus medius, which does not translate perfectly), many patients have impressively bulky musculature at this site. The middle scalene is also completely resected while approaching the first rib; perhaps removing this as well contributes to the excellent results we see today.
Third, the entire portion of the rib involved in NTOS (and the entire rib altogether if a paraclavicular approach is used) is very easily removed using this approach, as are any cervical ribs or Roos bands. Everything is seen, and everything can be evaluated and resected. Finally, many consider full neurolysis of the brachial plexus in this area an important part of the procedure. This is based on low-grade evidence only,3 but in the author’s experience, the incidence of improvement or cure seems to be higher, and recurrence rates lower, than with less-complete operations.
