Patient information on thoracic outlet syndrome and cervical or first rib removal

Who is this leaflet for and what is its aim?

This leaflet is for patients who have been diagnosed with a thoracic outlet syndrome and have been recommended to have cervical or first rib removal.

This leaflet aims to explain the procedure and its risks.

Background information

About 1 in 100 people have an extra rib in the neck called a cervical rib. This extra rib is just above the collar bone and is present from birth but not normally known about until later life. The extra rib often causes no symptoms at all but can cause symptoms of thoracic outlet syndrome if it presses onto the nerves or blood vessels.

Thoracic outlet syndrome is a condition in which the nerves and blood vessels (arteries and veins) in the neck, just behind the collar bone, become compressed (squashed).

There is a narrow space for the nerves and blood vessels to pass in between the collar bone and the first rib. If this space is too tight the nerves and blood vessels are compressed and this can cause pain, numbness, swelling and altered sensation in the arm. Often this is worse when the arm is elevated or when carrying heavy objects.

A cervical or first rib resection is carried out to reduce pain and to improve sensation and blood flow in the arteries in the arm. Sometimes separating the muscles from their attachments to the ribs and any fibrous bands around the nerves and vessels is sufficient to relieve symptoms. All the above procedures aim to create more space for the nerves and vessels as they pass under the collar bone.

The procedure

Once you are asleep, a small hole is made in the armpit or one just above the collar bone. Occasionally, another cut is made below the collar bone. The arm can be moved around a lot during this operation so it may feel sore for a few days afterwards. The first rib or cervical rib is removed taking care to try and preserve the nerves and vessels. Wounds are closed using dissolvable stitches. Sometimes a drain will come out of the skin near the wound, which helps to prevent any fluid collecting, and this is usually removed the next day.

Blood transfusion

During surgery, you may lose blood. If you lose a considerable amount of blood your doctor may want to replace the loss with a blood transfusion as significant blood loss can cause you harm. The blood transfusion can involve giving you other blood components such as plasma and platelets which are necessary for blood clotting. Your doctor will only give you a transfusion of blood or blood components during surgery, or recommend for you to have a transfusion after surgery, if you need it.

Compared to other everyday risks the likelihood of getting a serious side effect from a transfusion of blood or blood component is very low. Your doctor can explain to you the benefits and risks from a blood transfusion. Your doctor can also give you information about whether there are suitable alternatives to blood transfusion for your treatment. There is a patient information leaflet for blood transfusion available for you to read.

After the procedure

Once your surgery is completed you will usually be transferred to the recovery ward where you will be looked after by specially trained nurses, under the direction of your anaesthetist.

The nurses will monitor you closely until the effects of any general anaesthetic have adequately worn off and you are conscious. They will monitor your heart rate, blood pressure and oxygen levels too.

You may be given oxygen via a facemask, fluids via your drip and appropriate pain relief until you are comfortable enough to return to your ward.

Some patients recover from aneurysm surgery in the theatre recovery area for the first night. However, you may go back to the ward on the day of surgery if there are no problems in recovery.

Sometimes, people feel sick after an operation, especially after a general anaesthetic, and might vomit. If you feel sick, please tell a nurse and you will be offered medicine to make you more comfortable.

At this time, you might find there is a urinary catheter inserted into your bladder, which allows your urine to drain into a bag. This is a temporary measure to prevent urine becoming retained which can cause your blood pressure to become unstable.

After certain major operations you may be transferred to the intensive care unit (ICU/ITU), high dependency unit (HDU), intermediate dependency area (IDA) or fast track/overnight intensive recovery (OIR). These are areas where you will be monitored much more closely because of the nature of your operation or because of certain pre-existing health problems that you may have. If your surgeon or anaesthetist believes you should go to one of these areas after your operation, they will tell you and explain to you what you should expect.

If there is not a bed in the necessary unit on the day of your operation, your operation may be postponed as it is important that you have the correct level of care after major surgery.

Intended benefits

To help relieve compression of the nerves and blood vessels.

Risks

The rib that is removed is located in a confined space and is closely related to several nerves and blood vessels. Your surgeon will carefully move these away from the rib before it is removed. There is a reported risk of injury to the nerves or blood vessels in the neck and the arm but this is small: about 1 in 100.

This operation involves removal of a rib, so sometimes air can seep into the chest cavity and cause a partly deflated lung. This is uncommon and can easily be dealt with. This rarely requires any further treatment if it is small. Occasionally if a larger part of the lung deflates a chest drain may be required. This is a tube that drains air out of the chest cavity and allows the lung to fully inflate. If this happens you would need to stay in hospital for a few more days. Further X-rays are needed to ensure the lung has fully recovered.

There is also a risk that your symptoms may not fully improve, however this is low and the majority of patients who have this operation gain an improvement in their symptoms. As with any operation there is a risk of wound infection, but this is low.

Severe damage to the arm circulation, possibly leading to amputation has been reported with this operation due to injury of the artery in the neck but this is extremely rare. Permanent nerve damage is possible but also very rare.

General risks associated with all major operations and from being hospitalised: e.g. bleeding, infection, blood clots.

Alternatives

For many people with thoracic outlet syndrome the symptoms can be managed without the need for an operation. Physiotherapy may be helpful to improve the strength of the muscles in your neck and shoulder and help with poor posture.

An alternative to this surgery is a decision not to have surgery. We will discuss with you the implications of deciding not to have surgery.

Medication

Bring all of your medicines (including inhalers, injections, creams, eye drops or patches) and a current repeat prescription from your GP.

Please tell the ward staff about all of the medicines you use. During your stay If you wish to take your medication yourself (self-medicate) please speak with your nurse. Pharmacists visit the wards regularly and can help with any medicine queries.

MyChart

We would encourage you to sign up for MyChart. This is the electronic patient portal at Cambridge University Hospitals that enables patients to securely access parts of their health record held within the hospital’s electronic patient record system (Epic). It is available via your home computer or mobile device

More information is available on our website: MyChart

Contacts

We may give you additional patient information before or after the procedure, for example, leaflets that explain what to do after the procedure and what problems to look out for. If you have any questions or anxieties, please feel free to ask a member of staff or contact our Vascular Specialist Nurses via email or on 01223 348526.

Further information is available from:

• The Vascular Society website (opens in a new tab)
• Circulation Foundation UK website (opens in a new tab)