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First Rib Resection
First rib resection is the operative therapy used to treat Thoracic Outlet Syndrome.
The thoracic outlet is the area near the top of the chest, where the artery, vein and nerves come out of the chest to go to the arm.
The artery, vein and nerves pass between the clavicle or collarbone and the first rib, as they course thru the thoracic outlet.
There isn't a whole lot of space in the thoracic outlet. As the arm is lifted, the first rib and clavicle move closer, closing the space between those 2 bones.
If the artery, vein or nerves become pinched by the bones, the structures can become inflamed. This inflammation or injury to the structures is called Thoracic Outlet Syndrome.
Most cases of TOS involve compression of the nerves. This is called neurogenic TOS. It is thought that 97% of cases of TOS are neurogenic.
The "nerves" that course thru the thoracic outlet are called a plexus - a matrix of nerves. Farther out in the arm, the specific nerves arise out of the plexus.
The ulnar nerve is the most commonly affected portion of the plexus. When the ulnar nerve is pinched, numbness and tingling can result in the 4th and 5th digits (ring and pinky fingers). Some patients feel a sharp pain shooting down the arm, similar to hitting the "funny bone" near the elbow.
Pain can result in the hand and arm. Some patients have pain that creeps up into the shoulder and neck.
Anyone can develop neurogenic TOS. But people who work with their hands elevated - such as painters and hairdressers and some athletes - can be at higher risk for developing TOS.
Many patients with TOS have a history of trauma to the neck or back or shoulder.
Some patients with TOS have an extra rib. This is terms a cervical rib - a rib in the neck. Cervical ribs occur in about 1 in 500 people.
About 2% of cases of TOS are the venous form, where the axillary vein is compressed and injured. The vein eventually develops a clot that impairs blood return from the arm and the arm and hand become swollen and blue.
This venous form of TOS has a particular name = effort thrombosis, or Paget-Schroetter Syndrome.
Many patients with PSS go to the ER, because the arm looks and feels so unusual.
The clot is usually diagnosed with an ultrasound. A CT scan can also be used to make the diagnosis.
With PSS, the first step in therapy is to work to dissolve the clot, typically with catheter-directed thrombolysis. This is performed by Interventional Radiology or Vascular Surgery.
This will help to prevent the clot from worsening.
The next step is to remove the first rib, in order to prevent ongoing injury to the vein. Usually, in time, after the rib is removed, the vein will heal and the clot resorb.
Most patients with PSS are also treated with an oral blood thinner. This is often continued for 3-6 months.
About 1% of cases of TOS are the arterial form, where the axillary artery is compressed and injured. When the artery is compressed and injured, the fingers and hand can turn white and cold.
To perform first rib resection for TOS, there are several options for surgical access:
SUPRA-CLAVICULAR
TRANS-AXILLARY
ROBOTIC
A supraclavicular approach goes above the clavicle (aka collarbone) to access the first rib.
Often a second incision beneath the clavicle is also needed.
Though the scar(s) is not typically noticeable , many young patients do not prefer to have a scar near the neck.
Dr. Pool does not prefer a supraclavicular approach for first rib resection.
This option is often favored by Vascular surgeons.
A trans-axillary approach goes near the hairline of the armpit.
The scar for a trans-axillary approach is often hidden by clothing and/or the arm hanging by the side.
Dr. Hal Urschel was a pioneer in the field of TOS and Dr. Pool learned the trans-axillary approach for first rib resection from him.
A trans-axillary first rib resection typically takes 1 hour to perform, and patients are usually in the hospital 1-2 days.
Dr. Pool has performed many first rib resections with a trans-axillary approach.
A robotic approach uses small incisions between the ribs on the side of the chest.
The robotic camera allows 10x magnification of the thoracic outlet which can help in identifying the anatomic structures.
A robotic first rib resection typically takes 1 hour to perform, and patients are usually in the hospital 1-2 days.
Dr. Pool has performed many first rib resections with a robotic approach.
Dr. Pool usually uses 4 small incisions.
Dr. Pool has co-authored several book chapters on TOS. These include:
Thoracic Outlet Syndromes, Harold Urschel, J. Mark Pool, Amit Patel; Adult Chest Surgery, 2ed; McGraw-Hill Education 2015.
Controversies in NTOS: Is NTOS Overdiagnosed or Underdiagnosed? Harold C. Urschel Jr., Charles R. Crane, J. Mark Pool, and Amit N. Patel; Thoracic Outlet Syndrome, Springer 2013.
Surgical Techniques: Posterior Approach for Reoperative NTOS; Harold C. Urschel Jr., Charles R. Crane, J. Mark Pool, and Amit N. Patel; Thoracic Outlet Syndrome, Springer 2013.
Anatomy and Pathophysiology of VTOS; Harold C. Urschel Jr, J. Mark Pool, and Amit N. Patel; Thoracic Outlet Syndrome, Springer 2013.
First rib video
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