Hi People!

Does anyone know...

Do all surgeons perform a neurolysis at the time of initial surgery? Is this considered standard practice?

It seems to me that if the surgery is done through a transaxillary approach(Gelabert/Freischlag/others), the doctor wouldn't have access or full visualization of the plexus to even do a complete neurolysis?

For Donahue patients (supraclavicular approach) -- does he typically do a neurolysis with the initial procedure?

Any info or thoughts would be very much appreciated! Thanks in advance...

Dr. Avery did my surgery, supraclavicularly, and he did a neurolysis of the brachial plexus at that time, too.

Take care,
Kelly

If you have NTOS, I would think that the internal neurolysis -- and how well it's performed -- is critical to your outcome. Of course, I recognize that other factors are equally as important (post-op complications, post-op scarring, and so many others!) .

I am wondering why anyone with NTOS would have a surgery with a transaxillary approach, if this step couldn't be done completely.

In my case (true neurogenic TOS), in addition to a L first rib resection, Drs. Ahn and Annest both proposed neurolysis of the C-8 and T-1 nerve roots plus the lower trunk of the brachial plexus, as well as lysis of the subclavian vessels (artery and vein), using the transaxillary approach. The latter performed my decompression surgery in 2005 and these procedures are a part of the surgical report.

The question of access to and adequate visualization of the brachial plexus was not an issue by virtue of the method of surgical approach in my case. But I understand your point, and I do recall reading in the literature that a supraclavicular approach is touted by some TOS surgeons as affording more direct visualization and/or access to the neurovascular bundle.

On the other hand, there is an argument that full excision of the first rib is more easily achieved using the transaxillary approach, so maybe it's a trade-off. There seem to be valid arguments to each approach; I think it is largely a matter of the surgeon's preference as well as the particulars of each individual case (i.e., whether the compression is largely soft tissue or bony [or both]). I've even heard of at least one case where the TOS patient was given a choice between the two approaches (although the surgeon seems to have gone in both over the collarbone and under the arm during the actual operation, unbeknownst to that patient [!]).

As far as I know, regardless of the surgical approach, lysis and neurolysis of the affected vessels and nerves are fairly standard practices, not only in the initial TOS surgery but in any subsequent "re-do" surgery as well, as scar tissue builds up and compresses these structures in the thoracic outlet.

Just my 2 cents on this, based on my own research (9 years ago now) and personal experience with TOS surgery…

But you've got me curious about something. Does anyone know whether Annest has since changed his approach preference now that he is partnered with Dr. Sanders (who mostly performed supraclavicularly as he primarily did scalenectomies when he was active as a surgeon, unless he saw specific rib involvement once he was "in"), or vice versa?

If so, do they vary it case by case (based on testing and clinical findings), to individualize it to each new surgical TOS candidate presented to their office?

Hello,
Thanks for all your input to the issue of neurolysis. My understanding is that this is surgical removal of scar tissue around the nerve roots ( Is this correct?)

Also, How did your doctors make the diagnosis of scar tissue vs. recurrence of TOS or other complications? Did they use specific tests or imaging studies. I suspect that I have scar tissue in the nerve root but my doctor is having a hard time with this Dx. He does not trust the imaging studies.

Back in 2005, I visited Dr. Richard Sanders who had recommended a neurolysis of my Brachial Plexus through the Supraclavicular approach. I did not have the surgery as my understanding is that all too often the scar tissue grows back ( Is this correct??? Has anyone had successful scar tissue removal from the nerve roots in the Brachial Plexus???)

I am wary of having any other surgery to remove scar tissue until they can:
1) Identify it as the source of the problem
2) Ensure that it does not grow back

I would love your comments
Marc
California
Bilateral TOS decompression Supraclavicular ( Dr. Sanders)
Follow up First Left Rib removal and neurolysis of lower Brachial Plexus under armpit approach ( Dr. Gelabert)

You ask some very good questions. For me, it's one of the reasons why surgery should be a last resort with TOS. There's always a risk, with any surgery, that adhesions (or scar matter), will form… it's just that with this particular surgery, the area of the body it's performed in makes it tricky, in that the resected scalene muscles, for example, might decide to attach to the pleura, or to the neurovascular bundle, instead of obediently atrophying up the neck as is hoped. Causing all kinds of hell to break loose, recurrence of TOS symptoms chief among them…

Not really sure how the docs diagnose adhesions as being the culprit in a given case of recurrent TOS which has already been treated surgically, except that it is so common… and it does show up on imaging techniques used in pain management measures like Botox injections, nerve blocks, etc. (like fluoroscopy with ultrasound, for example, which Dr. Jordan uses).

TOS surgeons have tried various means to wrap the nerves in Seprafilm and the like, to keep scar matter from forming - or to keep it at a minimum - but with not very good results to-date. It's a problem, no way 'round it.

You might want to have a look at Sharon Butler's site: www.selfcare4rsi.com/thoracic-outlet.html, paying particular attention to her ideas concerning fascia, which may be relevant here in terms of nonsurgical treatment for some of your symptoms…

Some people naturally form more scar matter than others, for some reason. Which is another medical mystery! I happen to fall into the "more" category; just lucky that way, I guess! :roll eyes: (I've been putting additional TOS surgery off for years now…)

My (limited) understanding of what is involved in the lysis of veins and arteries and the neurolysis of nerves, is that the surgeon literally has to go in there and scrape off the offending scar tissue. Ye gads! Some people just have all the fun.

I'm sorry that you're still having trouble despite the surgical (and, I'm sure, other) remedies you've tried to help manage your TOS. It can be a lifelong "challenge," for sure. Don't know if I've answered any of your questions, but hope you'll keep posting here to let us know how you're doing. Have a relaxing Sunday, at any rate!

Alison

JKL626 can you post a bit about the FMT sessions you took and whether they helped? I have one series (very expensive) of 20 sessions scheduled with a FMT PT and am concerned whether its safe (the investment apart). Heard if PTs are aggressive, its an issue

Dr. Donahue does. Sanders had a paper on it.

Thank you for all the replies!

Sea Pines: I think you are correct regarding the transaxillary approach. I appreciate your thoughtful and informative response.

I just recently read this:
The advantage of this approach is that it gives the surgeon easy access to the first rib, artery and vein and lower brachial plexus without disturbing the rest of the brachial plexus. It also means the surgeon has limited access to the areas of the upper nerves and muscles.

It sounds like the transax approach was the right way to go in your situation.

Regarding neurolysis, I think I misunderstood the term initially. It appears "neurolysis" is used loosely to refer to both external neurolysis and internal neurolysis. Seems internal neurolysis is rarely done/needed, although I *wonder* if this step is especially important for NTOS outcomes. Perhaps I'll start another thread to gather opinions on this...

thanks again -

Hello did the neurolysis help? I was wondering if i help get the nerves to innervate the muscles.


Thanks,

Jeff