Minimally invasive resection of a prominent transverse process in neurogenic thoracic outlet syndrome: new application for a primarily spinal approach. Illustrative case

Marc Hohenhaus Department of Neurosurgery, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany

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Johann Lambeck Department of Neurology and Clinical Neurophysiology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; and

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Nico Kremers Department of Neuroradiology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany

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Jürgen Beck Department of Neurosurgery, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany

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Christoph Scholz Department of Neurosurgery, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany

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Ulrich Hubbe Department of Neurosurgery, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany

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BACKGROUND

The optimal surgical approach to treat neurogenic thoracic outlet syndrome (nTOS) depends on the individual patient’s anatomy as well as the surgeon’s experience. The authors present a minimally invasive posterior approach for the resection of a prominent transverse process to reduce local muscular trauma.

OBSERVATIONS

A 19-year-old female presented with painful sensations in the right arm and severe fine-motor skill dysfunction in the right hand, each of which had been present for several years. Further examination confirmed affected C8 and T1 areas, and imaging showed an elongated C7 transverse process displacing the lower trunk of the brachial plexus. Decompression of the plexus structures by resection of the C7 transverse process was indicated, owing to persistent neurological effects. Surgery was performed using a minimally invasive posterior approach in which the nuchal soft tissue was bluntly dissected by dilatators and resection of the transverse process was done microscopically through a tubular retractor. The postoperative course showed a sufficient reduction of pain and paresthesia.

LESSONS

The authors describe a minimally invasive posterior approach for the treatment of nTOS with the aim of providing indirect relief of strain on brachial plexus structures. The advantages of this technique include a small skin incision and minor soft tissue damage.

ABBREVIATIONS

CT = computed tomography; MRC = Medical Research Council; NCS = nerve conduction study; nTOS = neurogenic thoracic outlet syndrome; SNAP = sensory nerve action potential

BACKGROUND

The optimal surgical approach to treat neurogenic thoracic outlet syndrome (nTOS) depends on the individual patient’s anatomy as well as the surgeon’s experience. The authors present a minimally invasive posterior approach for the resection of a prominent transverse process to reduce local muscular trauma.

OBSERVATIONS

A 19-year-old female presented with painful sensations in the right arm and severe fine-motor skill dysfunction in the right hand, each of which had been present for several years. Further examination confirmed affected C8 and T1 areas, and imaging showed an elongated C7 transverse process displacing the lower trunk of the brachial plexus. Decompression of the plexus structures by resection of the C7 transverse process was indicated, owing to persistent neurological effects. Surgery was performed using a minimally invasive posterior approach in which the nuchal soft tissue was bluntly dissected by dilatators and resection of the transverse process was done microscopically through a tubular retractor. The postoperative course showed a sufficient reduction of pain and paresthesia.

LESSONS

The authors describe a minimally invasive posterior approach for the treatment of nTOS with the aim of providing indirect relief of strain on brachial plexus structures. The advantages of this technique include a small skin incision and minor soft tissue damage.

ABBREVIATIONS

CT = computed tomography; MRC = Medical Research Council; NCS = nerve conduction study; nTOS = neurogenic thoracic outlet syndrome; SNAP = sensory nerve action potential

Neurogenic thoracic outlet syndrome (nTOS) results from compression of the inferior trunk of the brachial plexus within the upper thoracic aperture. The diagnosis and treatment of this condition can be challenging and may require an interdisciplinary approach.1,2 In most cases, the T1 nerve root is affected first, leading to sensory deficits and pain on the medial side of the forearm down to the thenar eminence and later progressing to paresis and atrophy of the thenar muscles. As the disease progresses, the C8 nerve root can also be affected, causing further spread of the sensory deficit to the ulnar edge of the hand, as well as atrophic paresis of the remaining hand muscles, including the hypothenar. Diffuse dull arm pain has also been reported by patients with nTOS, especially when carrying heavier objects, due to traction on the arm.2

Anatomical causes of compression on lower plexus structures include a rudimentary cervical rib or an elongated C7 transverse process and are often associated with a fibrous ligament extending to the first rib.2 This ligament lifts the inferior trunk caudally after it passes through the scalenus gap. In some instances, plexus structures can also be pressed against the edge of the scalenus anterior muscle.2

There are different therapeutic options, depending on the severity of symptoms. In unmanageable pain under conservative treatment or if paresis or even atrophy has already occurred, surgical decompression of the neuronal components is indicated.3 Several techniques have been reported: the anterior supraclavicular approach, which is the most common approach used to treat the upper brachial plexus; the transaxillary approach; and the posterior subscapular approach.3,4 There are also a few reports on minimally invasive approaches such as endoscopic and robot-assisted techniques.5,6 In any case, all structures that could potentially contribute to nerve compression, such as a cervical rib with or without fibrous ligaments, altered scaleni muscles, sharp-edged fascias or ligaments, or even constrictive scar tissue, should be systematically searched for and removed. However, there is no clear recommendation for any of the aforementioned approaches.4,7 Because the outcomes of invasive treatment are heterogeneous, the indication and type of approach should be discussed critically.4,8–10

We report on the use of an innovative, minimally invasive technique to treat a 19-year-old female with nTOS, which entailed surgical decompression with the removal of an elongated C7 transverse process through a posterior approach using a tubular retractor system.

Illustrative Case

History

A 19-year-old female presented with painful electric sensations in the area of the right supraclavicular fossa, which also radiated into the arm. Sensory symptoms were further observed at the thenar eminence, the ulnar side of the hand, and the forearm, all of which she had experienced since childhood. The patient reported a worsening of these symptoms when she carried heavy objects, such as her school bag, on her right-hand side. More recently, these symptoms had also occurred, depending on brachial position, such as when her arm was hanging down. The patient also reported that her right hand had become progressively weaker over the last few years.

Clinical Examination

Marked atrophy was observed in the small right-hand muscles, as well as in the thenar and hypothenar muscles. Functional assessment revealed palsy Medical Research Council (MRC) grade M2 in the abductor pollicis brevis muscle to palsy MRC grade M3 in the muscles involved in finger splaying and adduction, finger flexion, and thumb adduction and flexion. Reduced sensation to touch and pain was observed in dermatome areas C8 and T1. Radiating sensations into the right hand could be evoked by applying local pressure in the region of the right supraclavicular fossa. The Tromner reflex was absent on the right and present on the left.

Electrophysiology

Compound muscle action potentials were markedly reduced in the right median and right ulnar nerves. Distal motor latency and nerve conduction study (NCS) were normal in the ulnar nerve but could not be measured in the median nerve. No F-waves were absent in the ulnar nerve. Sensory nerve action potential (SNAP) was reduced and NCS was normal in the right medial antebrachial cutaneous nerve, whereas SNAP and NCS were both normal in the left medial antebrachial cutaneous nerve. Electromyography of the abductor pollicis brevis and abductor digiti minimi muscles right showed spontaneous activity with polyphasic motor unit action potentials and a reduced interference pattern with a firing rate >20 Hz.

Imaging

High-resolution nerve ultrasound depicted a bony structure at the level of the transverse process at C7 on the right side, which showed contact with the inferior trunk of the brachial plexus. A computed tomography (CT) scan revealed an elongated transverse process at C7 on the right-hand side. Merged CT/magnetic resonance imaging revealed contact with the middle and inferior trunk of the brachial plexus. The inferior trunk was slightly displaced at the site of contact (Fig. 1).

FIG. 1
FIG. 1

Fused three-dimensional T2-weighted magnetic resonance imaging and high-resolution CT of the thoracic outlet showing right-sided effects of the brachial plexus through the prominent transverse process of C7 (red circle). Axial CT image showing the predominant elongated transverse process on the right side directly behind the exiting nerve roots (inset).

Surgical Intervention

Due to progressive motor weakness in the patient’s right hand and the pain-induced limitations on daily activities, we indicated decompression of the inferior trunk of the brachial plexus via resection of the elongated C7 transverse process using a minimally invasive technique. After general anesthesia was induced, the patient was placed prone on a radiolucent table with her head in a skull clamp. The site of the incision was determined using an anterior-posterior fluoroscopic radiograph paramedian centered on the right transverse process at the level of C7. The skin incision was performed in a transverse orientation (about 25 mm in length). The subcutaneous tissue, nuchal fascia, and paravertebral muscles were then bluntly dissected to reach the target transverse process. Additional radiography was performed to verify the proper position of the dilatator (Fig. 2). Using several dilatators, a primary tubular retractor 20 mm in diameter was inserted. A fixable arm secured the final retractor, and the position of the retractor was verified via fluoroscopy. Using an operating microscope, the transverse process was visually identified, and the surrounding soft tissue was resected with bipolar forceps and rongeurs. Once the anatomical orientation was established, the transverse process was resected in a stepwise fashion using a high-speed diamond drill under continuous irrigation. Bony remnants were mobilized with microdissectors and resected with rongeurs. By following the length of the bone, the whole transverse process was resected under associated release of the local tensed ligaments and associated cranioventrally orientated plexus structures. The nerve roots were not dissected directly. After complete resection of all bony structures, the tubular retractor was removed under local coagulation, where necessary. The closure was done using three subcutaneous sutures followed by sterile liquid skin glue. The operation time was 1 hour 16 minutes, and blood loss was negligible. A schematic of the surgical approach is depicted in Fig. 3.

FIG. 2
FIG. 2

Radiographic image, anterior-posterior view, showing the right-sided inserted tube in the direction of the facet joint C7–T1 and the elongated C7 transverse process on the right side laterally of the tube. The dashed outlined area marks the area to be resected.

FIG. 3
FIG. 3

Anatomical illustration of the retractor position for resection of the prominent C7 transverse process. A: Reconstruction of the three-dimensional CT scan of a 19-year-old female with an elongated transverse process of C7 on the right side (white arrow). B: Lateral view on an anatomical model of the cervicothoracic junction with a corresponding elongated transverse process of C7 on the right side (red). C: Identical lateral view on the anatomical model with an exemplary inserted minimally invasive tubular retractor (60 mm in length and 20 mm in diameter). D: Corresponding view through the tubular retractor on the elongated transverse process for stepwise resection.

Postoperative Course

The postoperative course was satisfactory, with complete remission of pain and paresthesia in the right supraclavicular fossa and the right forearm and fingers after 3 months. There was no further progression of the fine-motor skill deficits in the right hand, and there was a subjective reduction in hand-muscle weakness. As expected, hand-muscle atrophy still persisted after 3 months. There was no need for continued analgesic medication, and the surgical scar appeared to heal well. The last examination 1 year after surgery revealed the continued absence of pain and almost complete restoration of sensory function, with only mild hypesthesia at the hypothenar eminence but no more paresthesia. The weakness in the small hand muscles had improved, with an isolated flexion and extension palsy of digitus IV and V (MRC grade M4). No other muscles showed signs of paresis.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

This case report describes the successful treatment of a typical case of nTOS in which a tubular retractor system was applied posteriorly to resect an elongated C7 transverse process. We aim to introduce this technique as an additional approach for treating a selected cohort of patients with nTOS.

The optimal surgical approach for decompression of the brachial plexus structures in nTOS is controversial.4,7 Several techniques have been reported in the literature, each with associated advantages and disadvantages. The anterior supraclavicular approach is the most common means of treating the upper brachial plexus and is familiar to neurosurgeons, plastic surgeons, and thoracic surgeons alike. Besides its frequent use in the treatment of many other plexus-related conditions, this approach allows excellent exposure of the neurovascular bundle before reaching the bony or ligamentous pathology, thus avoiding the risk of damage to clinically relevant structures.3 The disadvantages are a relatively large operation with a broad wound area. In addition, the first rib is usually difficult to access because of its deep position. The transaxillary approach is most commonly used by thoracic surgeons as a procedure for partial resection of the first rib, whereas the prominent transverse process of C7 or cervical rib is more difficult to reach, and the overall view of the surgical area is reduced.11–13 Only a few reports exist on endoscopic and robot-assisted techniques in the context of this approach.5,6 The posterior subscapular approach is rarely used, because the sharp dissection required to gain access to the paravertebral zone can cause significant trauma to the trapezius, rhomboid, and levator scapulae muscles.4 Reports concerning minimally invasive posterior procedures are rare. Hawks et al.14 reported a successful minimally invasive resection of the first rib through a costotransversectomy for a patient with nTOS.

Observations

The advantage of our technique is that it uses a minimally invasive retractor system to allow a posterior approach with just a small skin incision, thus avoiding sharp dissection of the muscles. This reduces soft tissue damage and associated local pain, which is otherwise associated with a more conventional posterior approach. Blood loss can be reduced, and wound healing is expedited, as in other minimally invasive spinal procedures.15 Due to the isolated resection of the bony structures that does not require further dissection of whole nerve structures, this intervention represents a straightforward technique when the distractor is positioned properly. However, experience in minimally invasive surgery through tubular retractors is required for this technique. In addition, it is important to note that a minimally invasive dorsal approach is only applicable in cases in which either the C7 transverse process or the vertebral rib is responsible for the tension in the plexus structures. Anything more ventrally localized or the presence of a prominent first rib precludes the use of this technique. Accordingly, we do not generally recommend this approach, especially for revision surgery or in traumatic cases. In cases of doubt, a conventional ventral approach should be used to facilitate optimal recovery of the patient.

Lessons

In summary, the purpose of this report was to demonstrate a minimally invasive posterior approach for decompression of the neurovascular bundle in nTOS, without sharp dissection of the muscles. This approach therefore reduces local trauma and postoperative pain. For application of this technique, experience in minimally invasive surgery through tubular retractors is mandatory.

Author Contributions

Conception and design: Hohenhaus, Lambeck, Kremers, Scholz, Hubbe. Acquisition of data: Hohenhaus, Lambeck, Kremers, Hubbe. Analysis and interpretation of data: Lambeck, Kremers, Beck, Hubbe. Drafting the article: Hohenhaus, Lambeck, Scholz. Critically revising the article: Hohenhaus, Lambeck, Kremers, Beck, Hubbe. Reviewed submitted version of manuscript: Kremers, Beck, Hubbe. Approved the final version of the manuscript on behalf of all authors: Hohenhaus. Administrative/technical/material support: Hohenhaus, Scholz, Hubbe. Study supervision: Beck, Scholz, Hubbe.

Supplemental Information

Previous Presentations

Parts of this paper were presented at the annual conference of the Spine Section of the German Society of Neurosurgery, March 17–18, 2023, in Regensburg, Germany.

References

  • 1

    Dorn P, Zehnder A, Kocher GJ Thoracic outlet syndrome: rare, often missed or over-diagnosed? Article in German. Praxis (Bern). 2021;110(7):391396.

  • 2

    Jones MR, Prabhakar A, Viswanath O, et al. Thoracic outlet syndrome: a comprehensive review of pathophysiology, diagnosis, and treatment. Pain Ther. 2019;8(1):518.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Hwang JS, Kim J, Kim S, Bae KJ, Lee Y, Baek GH Diagnosis of neurogenic thoracic outlet syndrome based on the clinical status. Ann Vasc Surg. 2021;76:454462.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Crutcher CL 2nd, Kline DG, Tender GC A modified, less invasive posterior subscapular approach to the brachial plexus: case report and technical note. Neurosurg Focus. 2017;42(3):E7.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Furushima K, Funakoshi T Endoscopic-assisted transaxillary approach for first-rib resection and neurolysis in thoracic outlet syndrome. Arthrosc Tech. 2021;10(1):e235e240.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Gharagozloo F, Atiquzzaman N, Meyer M, Tempesta B, Werden S Robotic first rib resection for thoracic outlet syndrome. J Thorac Dis. 2021;13(10):61416154.

  • 7

    Povlsen B, Hansson T, Povlsen SD Treatment for thoracic outlet syndrome. Cochrane Database Syst Rev. 2014;(11):CD007218.

  • 8

    Franklin GM, Fulton-Kehoe D, Bradley C, Smith-Weller T Outcome of surgery for thoracic outlet syndrome in Washington state workers’ compensation. Neurology. 2000;54(6):12521257.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Mingoli A, Feldhaus RJ, Farina C, et al. Long-term outcome after transaxillary approach for thoracic outlet syndrome. Surgery. 1995;118(5):840844.

  • 10

    Altobelli GG, Kudo T, Haas BT, Chandra FA, Moy JL, Ahn SS Thoracic outlet syndrome: pattern of clinical success after operative decompression. J Vasc Surg. 2005;42(1):122128.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Falconer MA, Li FW Resection of the first rib in costoclavicular compression of the brachial plexus. Lancet. 1962;1(7220):5963.

  • 12

    Gharagozloo F, Meyer M, Tempesta BJ, Margolis M, Strother ET, Tummala S Robotic en bloc first-rib resection for Paget-Schroetter disease, a form of thoracic outlet syndrome: technique and initial results. Innovations (Phila). 2012;7(1):3944.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    George RS, Milton R, Chaudhuri N, Kefaloyannis E, Papagiannopoulos K Totally endoscopic (VATS) first rib resection for thoracic outlet syndrome. Ann Thorac Surg. 2017;103(1):241245.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Hawks C, Herrera-Nicol S, Pruzansky ME, Jenkins AL 3rd. Minimally invasive resection of symptomatic cervical rib for treatment of thoracic outlet syndrome. World Neurosurg. 2020;139:219222.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Momin AA, Steinmetz MP Evolution of minimally invasive lumbar spine surgery. World Neurosurg. 2020;140:622626.

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  • FIG. 1

    Fused three-dimensional T2-weighted magnetic resonance imaging and high-resolution CT of the thoracic outlet showing right-sided effects of the brachial plexus through the prominent transverse process of C7 (red circle). Axial CT image showing the predominant elongated transverse process on the right side directly behind the exiting nerve roots (inset).

  • FIG. 2

    Radiographic image, anterior-posterior view, showing the right-sided inserted tube in the direction of the facet joint C7–T1 and the elongated C7 transverse process on the right side laterally of the tube. The dashed outlined area marks the area to be resected.

  • FIG. 3

    Anatomical illustration of the retractor position for resection of the prominent C7 transverse process. A: Reconstruction of the three-dimensional CT scan of a 19-year-old female with an elongated transverse process of C7 on the right side (white arrow). B: Lateral view on an anatomical model of the cervicothoracic junction with a corresponding elongated transverse process of C7 on the right side (red). C: Identical lateral view on the anatomical model with an exemplary inserted minimally invasive tubular retractor (60 mm in length and 20 mm in diameter). D: Corresponding view through the tubular retractor on the elongated transverse process for stepwise resection.

  • 1

    Dorn P, Zehnder A, Kocher GJ Thoracic outlet syndrome: rare, often missed or over-diagnosed? Article in German. Praxis (Bern). 2021;110(7):391396.

  • 2

    Jones MR, Prabhakar A, Viswanath O, et al. Thoracic outlet syndrome: a comprehensive review of pathophysiology, diagnosis, and treatment. Pain Ther. 2019;8(1):518.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Hwang JS, Kim J, Kim S, Bae KJ, Lee Y, Baek GH Diagnosis of neurogenic thoracic outlet syndrome based on the clinical status. Ann Vasc Surg. 2021;76:454462.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Crutcher CL 2nd, Kline DG, Tender GC A modified, less invasive posterior subscapular approach to the brachial plexus: case report and technical note. Neurosurg Focus. 2017;42(3):E7.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Furushima K, Funakoshi T Endoscopic-assisted transaxillary approach for first-rib resection and neurolysis in thoracic outlet syndrome. Arthrosc Tech. 2021;10(1):e235e240.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Gharagozloo F, Atiquzzaman N, Meyer M, Tempesta B, Werden S Robotic first rib resection for thoracic outlet syndrome. J Thorac Dis. 2021;13(10):61416154.

  • 7

    Povlsen B, Hansson T, Povlsen SD Treatment for thoracic outlet syndrome. Cochrane Database Syst Rev. 2014;(11):CD007218.

  • 8

    Franklin GM, Fulton-Kehoe D, Bradley C, Smith-Weller T Outcome of surgery for thoracic outlet syndrome in Washington state workers’ compensation. Neurology. 2000;54(6):12521257.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Mingoli A, Feldhaus RJ, Farina C, et al. Long-term outcome after transaxillary approach for thoracic outlet syndrome. Surgery. 1995;118(5):840844.

  • 10

    Altobelli GG, Kudo T, Haas BT, Chandra FA, Moy JL, Ahn SS Thoracic outlet syndrome: pattern of clinical success after operative decompression. J Vasc Surg. 2005;42(1):122128.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Falconer MA, Li FW Resection of the first rib in costoclavicular compression of the brachial plexus. Lancet. 1962;1(7220):5963.

  • 12

    Gharagozloo F, Meyer M, Tempesta BJ, Margolis M, Strother ET, Tummala S Robotic en bloc first-rib resection for Paget-Schroetter disease, a form of thoracic outlet syndrome: technique and initial results. Innovations (Phila). 2012;7(1):3944.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    George RS, Milton R, Chaudhuri N, Kefaloyannis E, Papagiannopoulos K Totally endoscopic (VATS) first rib resection for thoracic outlet syndrome. Ann Thorac Surg. 2017;103(1):241245.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Hawks C, Herrera-Nicol S, Pruzansky ME, Jenkins AL 3rd. Minimally invasive resection of symptomatic cervical rib for treatment of thoracic outlet syndrome. World Neurosurg. 2020;139:219222.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Momin AA, Steinmetz MP Evolution of minimally invasive lumbar spine surgery. World Neurosurg. 2020;140:622626.

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