الفهرس 
Historical NoteOnly 14 pages are availabe for public view
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Abstract
Dr. Urschel is one of the most experienced surgeons in the world when it comes to dealing with thoracic outlet syndrome. This includes his tremendous experience in dealing with recurrent symptoms following thoracic outlet decompression. That being said, most thoracic surgeons go the other way when faced with a patient with an upper-extremity pain syndrome. Vascular surgeons have picked up many of these patients, and it is not unusual to see the occasional vascular surgeon “specializing†in the treatment of thoracic outlet syndrome. The difficulty with thoracic outlet syndrome resides not in the surgical procedure but in making the diagnosis and deciding who should be operated on and when. It remains the opinion of many experts, including neurologists, that there are no characteristic, consistent, or reproducible objective findings that allow one to make a diagnosis of thoracic outlet syndrome. This, combined with the psychiatric overlay that often accompanies the syndrome, the frequency of litigation related to this problem, and the issue of work-related disability causes many surgeons to avoid dealing with these patients altogether. Other than the presence of a cervical rib, there is no anatomic abnormality that can be visualized on imaging studies, including both computed tomography and magnetic resonance imaging. Specifically this is the case when dealing with the patient with an upper-extremity pain syndrome as opposed to the patient with vascular or Paget-Schroetter syndrome. Results for patients treated for vascular compression are far more satisfying than those achieved for the much more common “neurogenic†compression patients. It has been my experience that patients with upper-extremity pain rarely are satisfied long term after operation. Often the early results are striking, but following a short interval these patients usually re-present with additional complaints. It is almost as if they have a “need†to have the pain syndrome. Relief of one set of symptoms usually is replaced by another.
The authors do not mention the need for a neurosurgeon or hand surgeon interested in peripheral nerve disease, but a combined approach with one of these specialists may be beneficial. The neurolysis of the brachial plexus may be more important than previously realized, and these specialists are more adept at dealing with these large nerves than
most thoracic surgeons. The question comes up as to how to deal with a cervical rib. If the cervical rib is to be resected, this probably should be done through a supraclavicular approach, which puts the neurovascular structures at greater risk. I base my approach on the size of the cervical rib. A large cervical rib probably should be resected via the supraclavicular approach, whereas a diminutive cervical rib can be best dealt with by a transaxillary resection of the first rib, which removes the adhesive bands that attach to the cervical rib but does not resect the actual accessory rib.
The video thoracoscope probably adds little to the transaxillary approach to the first rib especially if a lighted right-angled breast retractor is used. A special set of first-rib instruments with grooved and nongrooved Overholt periosteal elevators, special retractors, and angled and straight first-rib cutters is mandatory for a safe transaxillary first-rib resection. The key to the procedure is proper positioning of the upper extremity, which, in my opinion, needs to be held, not simply suspended with a weight, by an assistant who can move the arm at various times during the procedure to obtain the best exposure. The arm is prepped and covered with a stockinette to facilitate this. Despite the appropriate equipment and arm positioning, getting the posterior aspect of the rib remains difficult. The rib is divided and the anterior portion removed first. Then the posterior aspect of the rib is excised, but getting exposure of the transverse process is not easy. Use of the rongeur, as the authors point out, allows the surgeon to get the most posterior portion of the rib. There remains considerable doubt as to whether it is necessary to remove every last bit of the posterior aspect of the first rib to effect relief of the compression. This raises the question of whether there is ever an indication for a “re-do†procedure, and this clearly remains controversial.73