Second surgical treatment of recurrent thoracic outlet syndrome

Thoracic outlet syndrome (TOS) treatment remains a challenge in this context of functional pathology. After an initial surgical treatment, TOS may recur, and its management becomes a challenge again. We report our experience about recurrent-TOS after complete first rib resection and scalenotomy. After a new diagnostic assessment, and failure of physiotherapy, we performed a second surgical treatment. A 32-year-old patient presented with symptoms consistent with left-sided neurogenic thoracic outlet syndrome (NTOS). After the failure of physiotherapy, a first rib resection with anterior and middle scalenectomy via Roos-axillary approach was performed. He initially felt an improvement, allowing him to go back to work. At 9 months, the patient had recurrent TOS with left arm pain. At 18 months, he consulted our department. The examination revealed positive dynamic manoeuvres. For an objective assessment, the patient completed the Disabilities of the Arm, Shoulder and Hand score (DASH-score), and the Physical Component of Short-Form-12 score (PCS-SF12).DASH-score was 43.3 and the PCS-SF12 was 32.2. Electroneuromyogram shows a left plexus C8-T1 dysfunction. Dynamic ultrasound showed complete arteriovenous compression under the left clavicle at 30 degrees abduction. X-ray shows a complete resection of the first rib. Dynamic arteriography shows compression between the second rib and the clavicle, and a pectoralis minor compression syndrom. Our surgical management consisted of second rib resection with a posterior scalenectomy and section of the left pectoralis minor muscle, by Roos axillary approach, without complication. Dynamic manoeuvres are now negative. He no longer has paresthesia in his left hand. The DASH-score at 6 weeks is 16.6 and the PCS-SF12 is 46.5. This clinical improvement will continue throughout the first year of follow-up. The DASH-score is 1.7 at 6 months and 0.83 at 12 months. The PCS-SF12 is 51.7 at 6 months and 55.5 at 12 months. In the case of recurrent TOS, a new maximalist diagnostic management should be performed to clearly identify the etiology of the compression. In the event of failure of physiotherapy systematically proposed as first-line treatment, a surgical treatment can be performed. Resection of the second rib is a surgical option in case of a new costoclavicular compression.