A hand surgeon's further experience with thoracic outlet compression syndrome

Because hand surgeons frequently see patients with arm and hand pain, numbness, and tingling, it is important for them to recognize the possibility of the presence of thoracic outlet compression syndrome (TOCS). Approximately 40% to 50% of patients with this condition have associated peripheral nerve compression symptoms. Only about 10% of patients with suspected TOCS might show some objective evidence during physical examination and other examination modalities. For this reason, TOCS is one of the most overlooked, misdiagnosed, and underrated conditions. During the past 20 years (1989-2009) our surgical experience with combined-approach surgery for TOCS, involving transaxillary first rib resection followed by immediate transcervical anterior and middle scalenectomy, has been gratifying. During this period, more than 750 patients had this combined procedure. Between the end of 1989 and 2002 (13 years), 532 patients (many of whom were from out of state) had this kind of intervention. At the end of 2002, we surveyed our patients for the outcome of their surgery. Unfortunately, we were able to locate only 358 patients, and only 102 patients returned a mailed questionnaire. About 95 patients reported improvement of their symptoms. Since the beginning of 2003, more than 230 patients have had the same procedure. It is our impression that the outcome of the surgery in this last group of patients is at least as good as (if not better than) the earlier reported outcome in the first group of patients. The combined surgical approach to TOCS with transaxillary first rib resection and transcervical scalenectomy is the most complete procedure for total decompression of the thoracic outlet, with a much better rate of improvement of symptoms and a lower rate of recurrences. The surgical techniques of these two procedures are described.