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jwildt
05-27-2008, 12:53
I'm working on getting a guy into B/2/20 that has hit every possible road block. He's a former D-1 soccer player, fitness freak, and prior-service Navy: attended BUDS and was injured. He was questioned about Thoracic Outlet Syndrome during his physical for BUDS and was cleared to attend. We're not quite sure, yet, the impact this surgery will have for his SF physical, but welcome comments/insight.

His surgery consisted of re-section of his first rib, left side. Sorry Deltas for the Charlie description!

Thanks

swatsurgeon
05-27-2008, 15:55
No impairment as long as the nerves are okay to the arm.
Normal chest excursion/breathing, no increased risk of pneumothorax....losing the 1st rib is no big deal interms of form or function.

ss

Blitzzz (RIP)
05-27-2008, 16:53
I have been in Physical therapy for 15 years., and thoracic outlet syndrome can oft times be treated in Physical without surgery. Plenty of exercises and stretching. Blitz

Doc Dutch
06-01-2008, 14:41
Sir,

Interesting topic of concern. The answer lies with "it depends". The thoracic outlet problems can be varied and lie in the symptoms one is having. The clinician must get a good history and physical and do the appropriate test pre-operatively. Having said that and the correct procedure(s) done, the results can go very well for the patient. First, we must make sure of whether this was true thoracic outlet issues or inlet issues. If it was a venous problem then it was a whole set of other issues related to venous thrombosis. Hopefully, he did not have that and that his subclavian vein was never involved. Prognosis is guarded with these. Trust me, they can be a bear!

If it truly was thoracic outlet and therefore involved either the nerves or the subclavian artery, once the operation is completed, the first rib resected and the scalene muscles relaesed as well as webs or scar tissue, the symptoms should resolve post-operatively. He should be better than he was and be able to perform well in his physical fitness once he is out 6 to 8 weeks (as he will have recovered from his operation). The surgery, if done well and in experienced hands, will actually lead to better performance. The first rib does little for us and we can do nicely with the portion resected with no morbidity at its loss.

It is interesteing that he went into BUDs. There is a lot of overhead exercises initially such as carrying their heavy rubber rafts and lifting heavy logs over their heads. This would only make the scalene muscles stronger (hypertrophy) and cause further injury due to stenosis of the bilateral subclavian arteries and veins. The nerve would be entrapped more, so in this patient those overhead exercises should be minimized to de-emphasize the scalene development. For those that go to the gyms, it is referred to has the "military bench press" and involves lifting weight straight up at the shoulders. People with jobs that lift their arms straight up to work while standing such as mechanics under cars or airplane mainatainence workers or electricians, get thoracic outlet more than the general population and it is secondary to the hypertrophied scalenes and damage that might occur resulting in scarring. I did a numer of these operations in my vascular fellowship, mostly for venous occlusion. All were athletes at the university lifting wieghts above their heads. Tough anatomy in a very narrow space between the neck and the shoulder, but patients were very grateful when they did go on to heal. It is also one of the highest litigated cases in medicine and many surgeons no longer want to do these surgeries. They get referred to special centers like ours was.

A couple of things: first, check his physical examination for strength and muscle mass equivalency between the two sides with a measuring tape (biceps and forearm levels) and check the thenar and hypothenar muscles for mass equivalecy between the two sides as well as grip and flexion/extension resistences, 2) look for any collateralization of the veins at the level of the shoulder to see if the subclavian vein thrombosed and the body has developed collaterals around the blocked subclavian vein, 3) ask for the operating surgeons post-op notes to see what they said about the case and his follow-up in the clinic (the patient should be willing to release them to you to facilitate his career aspirations), 4) call the surgeon and speak to them directly to see if the patient's care has had complications and what their recommendations are or have been (perhaps they do not think it is a good idea and have consueled the patient and yet the patient does not tell you what the surgeon said), 4) if all of this shows that the patient did have a good result and the surgeon gives "the green light" to proceed, then the operation worked and he needs a yearly PFT to assess his condition or change in condition. As a side note, remember scalene hypertrophy and scarring can re-develop even with the first rib resection if the scalenes were not released, but the patient should re-present if there is any problem.

Good luck on this,

Dutch Matthews