Efficacy and Safety of Supraclavicular Thoracic Outlet Decompression: Results of 1,032 Patients with Thoracic Outlet Syndrome
Nikhil Panda*, Jacob Hurd, James Madsen, Jacob Anderson, Margaret E. Yang, Jon Sulit, Sangkavi Kuhan, Alexandra L. Potter, Yolonda L. Colson, Chi-Fu J. Yang, Dean M. Donahue
Surgery, Massachusetts General Hospital, Winthrop, MA
OBJECTIVE(S): We aimed to report efficacy and safety outcomes of a multidisciplinary treatment approach including supraclavicular thoracic outlet decompression and pectoralis minor tenotomy among patients with thoracic outlet syndrome (TOS). METHODS: Patients who underwent unilateral, supraclavicular thoracic outlet decompression (first, cervical, or C7 costovertebral resection) or pectoralis minor tenotomy for neurogenic, venous, or arterial TOS were identified from a prospectively maintained database. Demography, use of preoperative botulinum toxin injection, and participation in multidisciplinary evaluation were measured. The primary endpoints were composite postoperative morbidity and need for revisional surgery. Factors associated with increased risk of composite morbidity were identified with logistic regression. RESULTS: Among 2869 patients evaluated (2007-2021), 1032 underwent operative thoracic outlet decompression, including 864 (83.7%) supraclavicular first, cervical, or C7 costovertebral resections and 168 (16.3%) isolated pectoralis minor tenotomies. Predominant TOS subtypes were neurogenic (74.2%) and venous TOS (23.0%). Most patients (70.0%) underwent preoperative botulinum toxin injection and 56.3% reported symptomatic improvement. Prior to surgical consultation, few patients participated in physical therapy (10.9%). Median time from first evaluation to surgery was 136 days [IQR 55, 258]. Among the 864 patients who underwent supraclavicular thoracic outlet decompression, the median operative time was 171 minutes [IQR 133, 212] and blood loss was 30 milliliters [IQR 20, 50]. In this cohort, composite morbidity was 19.8% with 23 (2.7%) asymptomatic hemidiaphragm elevations, no brachial plexus injuries, 73 (8.5%) chyle leaks, 36 (4.2%) postoperative pneumothoraces, 41 (4.8%) air leaks, 3 (0.3%) bleeding events, and 14 (1.6%) reoperations for complications. Two patients with hemidiaphragm elevation required diaphragmatic plication; otherwise, there was no permanent phrenic nerve dysfunction. One chyle leak required thoracic duct ligation; the remainder were managed medically and with diet modification. There were no 30-day readmissions or deaths. Four patients (0.4%) required revisional thoracic outlet decompression. Factors associated with composite morbidity included age (OR 0.96, 95%CI [0.95-0.97], p<0.001), history of repetitive motion (OR 0.53, 95%CI [0.33-0.86], p=0.01), lack of improvement with preoperative botulinum toxin injection (OR 0.53, 95%CI [0.34-0.83], p=0.01), preoperative pain medication use (OR 2.77, 95%CI [1.89-4.09], p<0.001) and revisional surgery (OR 1.81, 95%CI [1.00-3.31], p=0.05, Table). CONCLUSIONS: We present the largest report of supraclavicular thoracic outlet decompression for the treatment of TOS. Based on a low composite morbidity and need for revisional operations, the supraclavicular approach is a safe, effective, and critical component of the multidisciplinary management of patients with TOS.
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