[cyclist]

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...

[kellysf]

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

Take care,
Kelly

[cyclist]

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.

[Sea Pines 50]

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?

[Eight]

Originally Posted by cyclist

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. Donahue does. Sanders had a paper on it.

[cyclist]

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 -

[jmfriedman1981]

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


Thanks,

Jeff

Originally Posted by Sea Pines 50

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 -

[Kitt]

Welcome jmfriedman1982.

[Sea Pines 50]

Quite possibly that is one of the goals of this procedure. Unfortunately, it is impossible to say, in my case, whether the neurolysis helped or not, because just a few weeks after my TOS surgery I had an accident at home which compromised the outcome…

If you're talking about reinnervating muscles which had atrophied as a result of nerve compression caused by TOS, that is another story. As of right now, I don't believe there is a way to bring those muscles back to health. But, what with stem cell research and other areas of medical/scientific development, who knows what the future may hold?

And as to the nerves themselves, I've been told that you should never give up on them, no matter how badly compressed they may have been! Once the source of compression has been identified and removed, there is always hope that the nerve will be restored, in time, to a healthy state.

Alison

[MarcB50]

Originally Posted by Sea Pines 50

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)