Relieving pain — removing ribs

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Posted: Tuesday, January 7, 2014 4:00 pm | Updated: 9:26 am, Wed Jan 8, 2014.

ST. LOUIS, Mo. (Ivanhoe Newswire) -- It’s a condition that causes pain, numbness, and tingling in the shoulder and arms. We’re talking about thoracic outlet syndrome, or TOS, and relieving the pain might mean removing body parts.

For Kami Bathon, staying active is a way of life.

“I was an extremely active person my entire life. I was a dancer and a soccer player,” Kami told Ivanhoe.

However, a year ago, this fitness enthusiast developed severe pain and numbness in her arm that severely limited her workouts.

“It would feel like something was tearing through my bicep. I went from being able to deadlift 250 pounds, to where I couldn’t pick up my purse from the car seat next to me,” Kami explained.

Kami had neurogenic thoracic outlet syndrome, or TOS. The nerves in her neck and shoulder were being compressed by bones and other tissues.

To relieve the pain, surgeon Robert Thompson first removed muscles in front of the nerves and cleared away scar tissue. Then, he removed muscles behind the nerves and took out a rib. Finally, he divided the pectoralis muscle.

“That gives the most thorough decompression of the nerves,” Robert W. Thompson, MD, Professor of Surgery (Vascular Surgery), Radiology, Cell Biology and Physiology; Director, Center for Thoracic Outlet Syndrome; Department of Surgery, Washington University School of Medicine, told Ivanhoe.

Two months after her surgery, Kami is feeling much better and she has a souvenir.

“They removed my first rib from the right side during surgery,” Kami said.

Now, she can focus on her workouts and not her pain.

Dr. Thompson says removing the first rib and some of the surrounding muscles will not cause any harm to the patients, as they can function without them. He says TOS is more common in athletes like baseball pitchers, who use repetitive arm motions.

MEDICAL BREAKTHROUGHS

RESEARCH SUMMARY

TOPIC: RELIEVING PAIN—REMOVING RIBS

REPORT: MB #3719

BACKGROUND: Thoracic outlet syndrome (TOS) is a group of disorders that occur when nerves or blood vessels become compressed between the collarbone and the first rib (thoracic outlet). This may cause pain in the shoulders and neck and numbness in your fingers. Causes of TOS include physical trauma from a car accident, repetivie injuries from job or sports-related activities, pregnancy, and certain anatomical defects (like having an extra rib). If a vein happens to become compressed, the arm may become swollen and will be sensitive to the cold. This is more common in women between ages 20-50. (Source: http://www.mayoclinic.com/health/thoracic-outlet-syndrome/DS00800 and http://www.nlm.nih.gov/medlineplus/thoracicoutletsyndrome.html)

TYPES: There are three types of TOS:

• Vascular thoracic outlet syndrome: This type occurs when one or more of the veins or arteries under the collarbone (clavicle) are compressed.

• Neurogenic (neurological) thoracic outlet syndrome: This form of TOS is characterized by compression of the brachial plexus, a network of nerves that come from the spinal cord and control muscle movements and sensation in the should, hand, and arm.

• Nonspecific-type thoracic outlet syndrome: This type is also called disputed thoracic outlet syndrome. Some doctors don't believe it exists, while others say it's a common disorder. People with this form of TOS have chronic pain in the area of the thoracic outlet that worsens with activity. (Source: http://www.mayoclinic.com/health/thoracic-outlet-syndrome/DS00800/DSECTION=symptoms)

TREATMENT: In some cases, physical therapy can be the best form of treatment for thoracic outlet syndrome patients. This therapy will strengthen the shoulder muscles to enhance the range of motion. Physical therapy may also help your posture and take the pressure off of your nerves and blood vessels. Minimally invasive surgery can help certain patients with neurogenic thoracic outlet syndrome. In a study published in Journal of Vascular Surgery, researchers studied 200 patients who were referred to the hospital for disabling neurogenic thoracic outlet syndrome from February 2008 to October 2011. Fifty-seven patients underwent pectoralis minor tenotomy (PMT). The remaining 143 patients had supraclavicular decompression combined with PMT (SCD+PMT). In both groups, the most common symptoms were pain in the arms, neck, and shoulders, as well as pain, weakness, and paresthesia of the hands. After surgery, 163 of the 200 patients (82%) reported significant and progressive improvement at the 3-month follow-up, including 43 of the patients who underwent isolated PMT (75%) and 120 who underwent the combined procedure (84%). (Source: http://www.medscape.com/viewarticle/779191)

FOR MORE INFORMATION, PLEASE CONTACT:

Robert W. Thompson, MD

Professor of Surgery (Vascular Surgery), Radiology, Cell Biology, and Physiology

Director, Center for Thoracic Outlet Syndrome

Department of Surgery

Washington University School of Medicine

(314) 362-7410

thompson@wudosis.wustl.edu

www.tos.wustl.edu


Robert W. Thompson, MD, Professor of Surgery (Vascular Surgery), Radiology, and Cell Biology, and Physiology; Director, Center for Thoracic Outlet Syndrome; Department of Surgery, Washington University School of Medicine in St. Louis, talks about a new treatment for thoracic outlet syndrome.

What is thoracic outlet syndrome?

Dr. Thompson: Thoracic Outlet Syndrome (TOS) is a group of conditions, that all relate to compression of blood vessels or nerves in an area of the body called the thoracic outlet. That area is in the base of the neck behind the collarbone and extending down to the front of the shoulder.

Has this condition been misdiagnosed in a lot of people?

Dr. Thompson:  In a lot of cases the diagnosis is difficult because symptoms of thoracic outlet syndrome may overlap with other conditions that are far more common. We distinguish the three different types of thoracic outlet syndrome as arterial, venous and neurogenic. The diagnosis of neurogenic TOS is particularly difficult and challenging so it can be easily overlooked and the diagnosis can be seemingly delayed, but in many cases that period of time is necessary to rule out other conditions.

Are we talking about venous TOS in particular or are all of them treated the same way?

Dr. Thompson: All of them typically involve a surgical approach to treatment, at least in our practice. Arterial TOS and venous TOS are almost always best treated surgically. Neurogenic TOS may be treatable with good results with physical therapy, but many of the patients that we see in a referral practice have had very longstanding and very severe symptoms. They often don’t respond to further physical therapy and they’re better candidates for surgical treatment.

Does it usually occur in athletes?

Dr. Thompson:  We see a lot of young active athletic people as part of our practice and they do seem to be more prone to getting TOS than maybe other people. However, we also see people across a wide range of the age spectrum, even into the sixties and seventies.

What causes it?

Dr. Thompson: TOS is typically caused by a combination of underlying variations in anatomy combined with some form of injury. You can envision that there is a predisposing anatomy in this area of the body, with a lot of variation particularly in terms of the muscles around the first rib and adjacent to the nerves. There is also usually some degree of predisposing injury, and the healing and scarring in the area after injury can result in compression of the nerves in neurogenic TOS, or the vein or the artery in the vascular forms of TOS.

Can it be injuries from childhood that maybe you didn’t even know you were suffering really because you’re a kid?

Dr. Thompson: Usually the types of injury that cause TOS are not from childhood but more of an overactive use of the arm at the time that the symptoms begin. We frequently see patients who have had repetitive strain injury in the workplace or with athletes. A baseball pitcher for example doing the same thing over and over with the arm elevated overhead may sustain repetitive strain of the muscles in the thoracic outlet, and the healing of those muscles and the scarring results in tightening of the anatomy around the nerves.

When you say the anatomy, does everyone have the rib bone that’s putting pressure on the nerve?

Dr. Thompson:  Some people, for example about ten percent of our patients, have a cervical rib or an extra rib arising one level above the first rib. This can be a complete rib or it can be a partial rib and its often thought of when people talk about thoracic outlet syndrome. Frankly, most of our patients don’t have an extra rib but they do have other variations in the muscular anatomy.

Why is it that you take out that rib when you’re treating TOS?

Dr. Thompson: When we treat neurogenic thoracic outlet syndrome surgically, we do a very thorough operation where we want to make sure that any of the contributing components of the anatomy are removed so that you don’t have persistent or recurrent symptoms. We remove the two scalene muscles that attach to the top of the first rib and we remove the first rib itself. We often find scarring around the nerves and we remove that as well, giving the most complete decompression of the nerves and therefore the most likely operation to give the best result.

Does it hurt the patient at all to have one less rib?

Dr. Thompson: No, you can remove the first rib, and you can remove the scalene muscles, without any imposed restriction or limitation in function or activity or structure.

This wasn’t something you just came up so you could give patients a rib?

Dr. Thompson: No, we know from many, many examples, virtually thousands of patients who’ve had surgery in removing the first rib, that you can do that and not impose particular limitations on them.

Now the difference that you’re doing now is before you’d have to do a large incision and really cause a lot of recovery time I think right, and now it’s less invasive?

Dr. Thompson: We now pay more attention to one part of the thoracic outlet where the pectoralis minor muscle comes up and attaches right over the nerve bundle. That’s just below the collarbone in front of the shoulder, and in treating that site of compression in many cases we can do an operation that just addresses the pectoralis minor muscle with good results. So we treat the pectoralis minor now as part of our routine approach if that site is involved in nerve compression, and that’s something that has probably been overlooked in the past. That may also be why previous results of surgery for TOS have been somewhat mixed. It is exciting for us is to find the occasional patient where the pectoralis minor tendon alone is responsible for nerve compression, because treating that site alone can be done with a relatively minor outpatient operation.

Is that what Kami had then?

Dr. Thompson: No, she had the full decompression operation with removal of the first rib and the scalene muscles as well as release of the pectoralis minor muscle.

Any long lasting effects from this, like when Kami is sixty is she going to have a problem with it?

Dr. Thompson:  No, but I think there is always a concern about recurrence in anyone who’s had surgery for neurogenic thoracic outlet syndrome. The most frequent cause is scarring around the nerves and that can occur in anybody. The overall rate of recurrence requiring a re-operation is around five percent. With other operations that are sometimes done for thoracic outlet syndrome, the recurrence rate can be much higher.

What is this most mistaken for?

Dr. Thompson: There is potentially overlap in symptoms between neurogenic thoracic outlet syndrome and problems of the cervical spine, problems of the shoulder, or problems in the peripheral nerves in the arm, such as with carpal tunnel syndrome. The symptoms of TOS can be similar to or mimic those conditions and of course those disorders are far more common than thoracic outlet syndrome.

How do you know the difference?

Dr. Thompson: The diagnosis involves a lot of different steps that include identifying things that fit well with thoracic outlet syndrome from the history and physical exam, and then excluding other conditions that might overlap.

What are some tell-tale signs?

Dr. Thompson:  Patients with neurogenic thoracic outlet syndrome typically describe symptoms that include pain, numbness, and tingling in the arm anywhere from the neck down into the hand. They typically describe that the symptoms have a radiating quality going down from the neck to the arm. They usually describe that the symptoms are worsened when they use the arm in an elevated manner and specifically overhead. On physical exam those patients will often have tenderness right over the nerves in the thoracic outlet area just above the collarbone or at the pectoralis minor level just below the collarbone. By identifying those areas of tenderness and reproduction of symptoms, we can identify positive features for thoracic outlet syndrome and by looking for other features we can exclude other conditions.

What would happen if she hadn’t figured it out almost accidentally?

Dr. Thompson: Well one of the problems is that people with TOS can get chronic nerve compression and chronic injury. People who go a long time without identification of the problem can suffer nerve injury and damage on a chronic basis, which may be very difficult to treat.

Is that repairable?

Dr. Thompson: Some patients do progress to a point where their symptoms are extremely difficult to treat and may not be reversible even with surgical treatment.

How long should you wait, you feel something in your arm what’s a good waiting period for patients like before they should say, this isn’t something that’s just going to work itself out?

Dr. Thompson: I think it depends on the symptoms you’re describing, but if you have severe pain and particularly numbness and tingling going from the neck down into the arm and hand, then that’s potentially a sign of thoracic outlet syndrome, but it could also be a sign of cervical spine problems or something else. The symptoms warrant evaluation for sure so you don’t want to go more than a few weeks with something like that before someone has looked at it. That someone could be an orthopedic surgeon or a cervical spine specialist, a physiatrist, or a chiropractor, and that evaluation may then lead to further testing. Ultimately someone with thoracic outlet syndrome will be found to have symptoms that fit with that diagnosis and hopefully would be referred within a period of several months.

How does the surgery work?

Dr. Thompson: I like to explain the anatomy of the thoracic outlet as this area above and behind the collarbone, where you have the first rib along with the anterior scalene muscle and the middle scalene muscle attaching to it. These muscles come from the spine and attach directly to the top of the first rib. The brachial plexus nerves come from the cervical spine from C5 down to T1, so there are five different nerve root levels involved. The nerve roots come out independently, but then begins to bundle together and form the brachial plexus. That’s what passes between the two scalene muscles and over the first rib, in the area we call the scalene triangle, where compression can occur. The brachial plexus then passes underneath the collarbone and in front of the shoulder, where compression by the pectoralis minor muscle can occur. The pectoralis minor muscle comes from the second, third and fourth ribs and attaches to a bony prominence next to the shoulder and it lies immediately in front of the nerve bundle. The surgical treatment that we use for thoracic outlet decompression is to make an incision above the collarbone just in front of the scalene triangle. We expose this area with the muscle and the brachial plexus immediately behind it and then remove the anterior scalene muscle. We then remove the middle scalene muscle as well, followed by the first rib.

You don’t need those muscles?

Dr. Thompson: You can do without them.

Does it make your neck weaker?

Dr. Thompson: No, the strength of the neck really resides in other muscle groups, you really don’t need the scalene muscles. Relative to the other muscles of the neck these are pretty small, so they are almost accessory muscles.

When you explain this to people are they surprised to see a rib bone so high up?

Dr. Thompson: I explain that the chest is shaped like a cone and the top rib naturally is smaller than the ribs out at the side that they might be used to thinking of. It’s like that in any chest cavity, the top rib is going to be small and short and you can remove that without really inducing any weakness or structural deficit. After we’ve removed the scalene muscles and the first rib we then expose the nerves. We clean off any scar tissue that might surround the nerves as well. We ensure that the nerves are fully mobile throughout this entire space. To treat the pectoralis minor area we make an incision in front of the shoulder, using a short up-and-down incision. We lift the pectoralis major muscle and identify the tendon of the pectoralis minor and in that case simply divide the muscle and it contracts down and away from the nerve bundle and the nerve bundle is then free. That would be our typical approach to somebody with neurogenic thoracic outlet syndrome with compression at the scalene triangle and the level of the pectoralis minor tendon.

This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.

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