Recurrent thoracic outlet syndrome after first rib resection.

After initial relief of severe thoracic outlet syndrome by transaxillary resection of the first rib, a few patients may gradually develop recurrent neurologic symptoms in the neck, shoulder, arm and hand caused by postoperative scar tissue entrapment of segments of the brachial plexus. Once they begin, these symptoms may relentlessly progress to the extent they become unresponsive to all forms of conservative management. Two distinct patterns of recurrent TOS, which may occur separately or simultaneously, have been identified. Clinical measures that have proved effective in establishing the diagnosis of these types, the surgical techniques developed to offer relief, and measures to help prevent recurrence are discussed in this paper. A series of 76 patients who underwent operation for disabling recurrent TOS is presented. The principals of the etiology, diagnosis and surgical treatment described have offered significant, if not total, relief of the severe symptoms. The operations which have proved to be the most effective, however, are high-risk, technically demanding procedures which should be performed only by surgeons with wide experience in the anatomy and surgery of the thoracic outlet region. Although these techniques may offer patients significant relief, prevention of the recurrent thoracic outlet syndrome is still the best cure.