Of more than 15,000 patients evaluated for TOS, 3914 underwent primary neurovascular
decompression procedures and 1221 underwent second
surgical procedures for recurrent symptoms. Of 2210 consecutive patients, 250 had symptoms of upper plexus compression only (median nerve), 1508 had symptoms of lower plexus compression only (ulnar nerve), and 452 patients had symptoms of both. Ulnar and median nerve conduction velocities confirmed the clinical diagnosis. Transaxillary first rib removal alone for neurovascular
decompression relieved both upper and lower plexus symptoms (without a combined transaxillary and supraclavicular approach). There are two reasons for this: most upper compression mechanisms attach to the first rib, and the median nerve is also supplied by C8 and T1 as well as C5, C6, and C7 nerve roots. Axillary subclavian artery
aneurysm or occlusion was treated successfully in 240 patients. Dorsal
sympathectomy was performed concomitantly in 71 patients for occlusion or
embolectomy. It was combined with first rib resection in 1974 patients for sympathetic maintained
pain syndrome and
causalgia that did not improve with
conservative therapy. Of 264 patients with effort
thrombosis (
Paget-Schroetter syndrome), 211 were treated by
urokinase thrombolysis and prompt first rib resection with excellent long-term results. Recurrent TOS symptoms required a second procedure using the posterior approach in 1221 patients with brachial plexus neurolysis and dorsal
sympathectomy. The use of
hyaluronic acid significantly reduced recurrent
scarring.