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:
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.
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.
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.
2. Thoracic Outlet Syndrome. London: Springer 2013 ; 319-21.
4. Thoracic Outlet Syndrome. London: Springer 2013 ; 315-7.