Recurrent neurogenic thoracic outlet syndrome



      Although 90% of patients with neurogenic thoracic outlet syndrome (NTOS) experience “excellent” or “good” results after thoracic outlet decompression, recurrent symptoms may develop in certain patients.


      This is a retrospective review of patients with NTOS who developed recurrent symptoms of upper extremity/shoulder/neck pain, weakness and limitation of motion at least 3 months after initial relief of symptoms by surgical decompression. Diagnostic procedures and outcomes of reoperative surgery were assessed.


      Among almost 500 patients undergoing initial successful thoracic outlet decompression for symptoms of NTOS during the last decade, 17 redeveloped classic NTOS symptoms (3 of them bilaterally) at intervals from 3 to 80 months (mean 18 months) after the initial operative procedure. Ultimate diagnoses included incomplete first-rib resection (n = 1), compression of the brachial plexus by an ectopic band (n = 1), persistent brachial plexus compression by an intact first (n = 2) or second (n = 1) rib, brachial plexus compression by the pectoralis minor tendon (n = 13) and adherent residual scalene muscle (n = 14). Anterior scalene muscle block was positive in 9 patients later found to have recurrent symptoms from adherent residual scalene muscle. Among these 20 cases of osseous or musculotendinous causes of recurrent NTOS, all had “excellent” or “good” results from repeat surgery to eliminate the underlying structural problem (removal of intact or residual rib, pectoralis minor tenotomy, brachial plexus neurolysis, or a combination of these).


      Complete excision of cervical or first ribs and subtotal excision (instead of simple division) of the scalene muscles will decrease the incidence of recurrent NTOS. Pectoralis minor tenotomy should be considered part of complete thoracic outlet decompression. Anterior scalene muscle block accurately predicts outcome of reoperation for certain types of recurrent NTOS.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Wilbourn A.G
        • Porter J.M
        Neurogenic thoracic outlet syndrome.
        J Vasc Surg. 1992; 15: 880-888
        • Landry G.J
        • Moneta G.L
        • Taylor L.M
        • et al.
        Long-term functional outcomes of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients.
        J Vasc Surg. 2001; 33: 312-319
        • Thomas G.I
        • Jones T.W
        • Stavney L.S
        • et al.
        The middle scalene muscle and its contributions to the TOS.
        Am J Surg. 1983; 145: 589-592
        • Reilly L.M
        • Stoney R.J
        Supraclavicular approach for thoracic outlet decompression.
        J Vasc Surg. 1988; 8: 329-334
        • Green R.M
        • McNamara M.S
        • Ouriel K
        Long-term follow-up after thoracic outlet decompression.
        J Vasc Surg. 1991; 14: 739-746
        • Loh C.S
        • Wu A.V.O
        • Stevenson I.M
        Surgical decompression for thoracic outlet syndrome.
        J R Coll Surg Edinb. 1989; 34: 66-68
        • Dillon A.L
        The results of supraclavicular brachial plexus neurolysis (without first rib resection) in management of post-traumatic thoracic outlet syndrome.
        J Reconstr Microsurg. 1993; 9: 11-17
        • Roos D.B
        Technique of transaxillary decompression for thoracic outlet syndrome.
        in: Yao J.S.T Pearce W.H Techniques in Vascular and Endovascular Surgery. Appleton and Lange, Stamford, CT1997: 531-538
        • Hempel G.K
        • Schutze W.P
        • Anderson J.F
        • et al.
        770 consecutive supraclavicular first rib resections for thoracic outlet syndrome.
        Ann Vasc Surg. 1996; 10: 456-463
        • Axelrod D.A
        • Proctor M.C
        • Geisser M.E
        • et al.
        Outcomes after surgery for thoracic outlet syndrome.
        J Vasc Surg. 2001; 33: 1220-1225
        • Franklin G.M
        • Fulton-Kehoe D
        • Bradley C
        • et al.
        Outcome of surgery for thoracic outlet syndrome in Washington state worker's compensation.
        Neurology. 2000; 54: 1252-1257
        • Baxter B.T
        • Blackburn D
        • Payne K
        Noninvasive evaluation of the upper extremity.
        Surg Clin North Am. 1990; 70: 87-97
        • Jordan S.E
        • Machleder H.I
        Diagnosis of thoracic outlet syndrome using electrophysiologically guided anterior scalene blocks.
        Ann Vasc Surg. 1998; 12: 260-264
      1. Quail F. Conservative management of thoracic outlet syndrome. In: Ernst CB, Stanley J, eds. Current Therapy in Vascular Surgery. 4th ed. Philadelphia, PA, Mosby: 2000, p 173–9

        • Novak C.B
        • Mackinnon S.C
        Thoracic outlet syndrome.
        Orthop Clin North Am. 1996; 27: 747-762
        • Sanders R.J
        • Haug C.E
        Thoracic Outlet Syndrome: A Common Sequela of Neck Injuries.
        Lippincott, Philadelphia, PA1991
        • Lord J
        • Stone P.W
        Pectoralis minor tenotomy and anterior scalenotomy with special reference to the hyperabduction syndrome and “effort thrombosis” of the subclavian vein.
        Circulation. 1956; 13: 537-542
        • Stallworth J.M
        • Quin J
        • Aiken A.F
        Is rib resection necessary for relief of thoracic outlet syndrome?.
        Ann Surg. 1977; 185: 581-592
        • Sanders R.G
        • Haug C
        • Pearce W.H
        Recurrent thoracic outlet syndrome.
        J Vasc Surg. 1990; 12: 390-400
        • Cheng S.W.K
        • Stoney R.J
        Supraclavicular reoperation for neurogenic thoracic outlet syndrome.
        J Vasc Surg. 1994; 19: 565-572
        • Cheng S.W.K
        • Reilly L.M
        • Nelken N.A
        • et al.
        Neurogenic thoracic outlet compression.
        Cardiovasc Surg. 1995; 3: 617-623
        • Sanders R.J
        • Hammond S.L
        Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome.
        J Vasc Surg. 2002; 36: 51-56
        • Edwards P.R
        • Moody A.P
        • Harris P.L
        First rib abnormalities in association with cervical ribs.
        Eur J Vasc Surg. 1992; 6: 667-681
        • Lindgren K.-A
        • Leino E
        Subluxation of the first rib.
        Arch Phys Med Rehabil. 1988; 68: 692-695
        • Sanders R.J
        • Raymer S
        The supraclavicular approach to scalenectomy and first rib resection.
        J Vasc Surg. 1985; 5: 751-756