Thoracic Outlet Syndrome

POSTOPERATIVE DIAGNOSIS: Right neurogenic and vasculogenic​

thoracic outlet syndrome.​

​

PROCEDURES PERFORMED:​

1. Right first rib resection. 21615-XS,RT​

2. Right brachial plexus neurolysis. 64713-RT​

3. Exploration lysis subclavian vessels. - Included​

4. Right anterior and middle scalenectomy. - Included​

5. Right pectoralis minor release. – 23405-RT​

6. Right phenic nerve and long thoracic nerve lysis (2 peripheral nerves) -Included or coded separately? ​

7. Placement of amniotic membrane bone graft as a nerve wrap. - Included​

FINDINGS: There was evidence of marked neurovascular​

compression thoracic outlet. The subclavian artery was​

markedly compressed, but no ectasia or aneurysmal change was​

noted. A scalenus minimus muscle with attached Sibson's​

fascia was present causing entrapment of the lower portion of​

the plexus against the 1st rib, particularly the T1 and C8​

nerve roots. The scalene muscles were large and well​

developed with dense fibrocartilaginous banding present and​

appeared to cause significant neurovascular compression within​

the scalene triangle. The rib was large and broad based and​

elongated and appeared to cause significant narrowing within​

the costoclavicular space, but no obvious bony abnormality or​

anomaly was identified. Pectoralis minor muscle was quite​

broad and taut with dense fibrocartilaginous banding present​

and appeared to cause significant neurovascular compression​

within the subpectoral space. The operative findings were​

otherwise unremarkable.​

​

TECHNIQUE: The patient was brought to the operating room and​

placed supine on the table. After induction of general​

inhalational anesthesia, the right neck and chest were​

scrubbed and painted with Betadine solution and draped in​

sterile fashion. A right transverse supraclavicular incision​

was then made and carried down through the platysmal layer. ​

The clavicular of the sternocleidomastoid muscle was partially​

divided with cautery. The scalene fat pad was elevated and​

reflected towards the midline exposing the underlying anterior​

scalene muscle. Lysis of the phrenic nerve was conducted and the ​

nerve was protected. Anterior scalene muscle was then transected off​

its insertion of the first rib, taking care to identify and​

protect the underlying subclavian artery. Anterior scalene​

muscle was then excised at its origins from the lower cervical​

vertebra. Complete mobilization and lysis of the subclavian​

artery was then performed with ligation and division of side​

branches. The subscapular and thyrocervical trunk arteries​

were ligated and clipped between silk ties. ​

The artery was then circumscribed with a vessel​

loop for purposes of gentle retraction. The scalenus minimus​

muscle and attached Sibson's fascia were then excised in their​

entirety allowing for release of the lower portion of the​

plexus and trapped against the 1st rib. Complete brachial​

plexus neurolysis as well as long thoracic nerve lysis ​

was then performed sharply and the lower​

portion of the plexus was then circumscribed with a vessel​

loop for purposes of gentle retraction. Underlying middle​

scalene muscle was then transected off its insertion of the​

first rib and excised at its origin from the lower cervical​

vertebra. Remaining muscular attachments to the rib including​

intercostal attachments were then divided sharply or with​

cautery or swept away with blunt digital dissection. The rib​

was then transected anteriorly at or near the costochondral junction​

of the manubrium sterni and transected posteriorly at its​

articulation with the transverse process of T1. The rib was​

then removed in its entirety. Hemostasis was obtained with​

cautery and with packing. A short incision was then made in​

the right deltopectoral crease and carried down to the​

pectoralis major muscle in muscle splitting fashion. ​

Pectoralis minor muscle was then identified and was gently​

separated from the underlying neurovascular structures with​

blunt dissection. Pectoralis minor tenotomy was then​

performed at its insertion of the coracoid process and short​

segment of muscle was then excised to prevent reattachment. ​

The clavipectoral fascia overlying the neurovascular​

structures was then incised to ensure no residual adhesive​

bands or compression within the subpectoral space. Amniotic​

membrane bone graft was then placed as a nerve wrap around the​

lower portion of the brachial plexus back to the T1, C8 and C7​

nerve roots. A #15 Blake drain was then placed through a​

separate stab incision with the tip of the drain placed into​

the extrapleural space. The scalene fat pad was​

reapproximated to cover the plexus with interrupted 3-0​

Monocryl sutures. The clavicular head of the​

sternocleidomastoid muscle was reapproximated with 0 Vicryl​

mattress sutures. The platysmal layer was closed with a​

continuous 3-0 Monocryl suture and the skin was closed with a​

4-0 Monocryl subcuticular stitch. Deltopectoral incision was​

closed with interrupted 2-0 Vicryl sutures and the​

subcutaneous tissue and skin was closed with 4-0 Monocryl​

subcuticular stitch. Dermabond was applied to the incisions. ​

The drain was placed to bulb suction. Estimated blood loss​

was 200 mL. Sponge, lap, needle and instrument counts were​

correct. The patient tolerated the procedure well and was​

taken to recovery room in stable condition.​

jnbentzel@gmail.com said:

If nerve lysis was performed, which it looks to be the case in your note, then 64713 would be the main procedure. 64713 includes 21615. I agree with your pec tenotomy code. I cannot comment on the grafting or the additional lyses. Hope this helps.

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