Choosing the transaxillary or supraclavicular approach for neurogenic TOS
Parenthetically, related to this issue is that of visualization and education. The primary goal is ensuring the best outcome for the patient. Visualization is, by far, best if a supraclavicular approach is used. This is beneficial clinically by ensuring the most complete decompression of the nerves and avoidance of complications, but also is extremely helpful with regard to educating residents and fellows, learning the anatomy, identifying aberrant structures, and so on. Even with the best techniques (including a head- or retractor-mounted camera), no one can see what’s going on during a transaxillary approach except for the operator.
If the supraclavicular approach allows better access to and removal of all the potentially involved components causing NTOS, why doesn’t everyone use it? One answer is that the potential complication rate may be higher. Both the long thoracic and phrenic nerves are very much more at risk using this approach than using the transaxillary approach, and, on the left side, the risk of thoracic duct injury is higher. It must be conceded that published results, in general, do not show significant differences in outcomes between the two approaches.4 However, many would interpret this as a type II error, combined with the “fuzziness” of diagnosis and evaluation of outcomes this field has labored under. However, the opposite interpretation should be considered – there are no definitive data showing any higher complication rate between the two approaches. This debate likely is answerable in the same fashion as many other such debates in our field – someone who is good at the transaxillary approach will do a better job than someone who is not, and someone who is good at the supraclavicular approach will do a better job than someone who is not.
Is a prospective trial indicated? In theory, yes. However, the relative rarity of this condition, the fact that most surgeons follow almost exclusively one or the other technique, and the categorical nature of the outcome variable make such a trial relatively impractical. Pending this, the best suggestion is obviously to pick the best TOS surgeon you can find and have him or her fix the problem in the way they are most experienced!
Dr. Illig is professor of surgery and director, division of vascular surgery, and associate chair, faculty development and mentoring, University of South Florida, Morsani College of Medicine, Tampa, Fla. He had no relevant disclosures.
References
2. Thoracic Outlet Syndrome. London: Springer 2013; 319-21.
