Surgical Techniques: Posterior Approach for Reoperative NTOS

The treatment of recurrent neurogenic thoracic outlet syndrome (TOS) is an exceptional challenge. We believe that in patients with symptoms suggesting recurrent neurogenic TOS, the clinical diagnosis should be confirmed by objective nerve conduction velocity (NCV) testing, and that when NCVs are depressed in a patient whose symptoms are unrelieved by prolonged conservative therapy, a posterior reoperative procedure should be considered. Removal of any cervical or first rib remnants or regenerated fibrocartilage, along with neurolysis of C7, C8, and T1 nerve roots and the brachial plexus, is performed. Dorsal sympathectomy is typically included to minimize any contribution to symptoms that might be attributable to causalgia and sympathetic-maintained pain syndrome, and topical agents are employed to minimize formation of recurrent perineural scar tissue. In this chapter, we summarize results with this approach in a large number of patients.