The transaxillary approach in the treatment of thoracic outlet syndrome: a neurosurgical appraisal.

OBJECT: Different surgical approaches are available for the treatment of thoracic outlet syndrome (TOS). Our aim is to describe the transaxillary approach from a neurosurgical perspective, and to present the results in 15 patients. METHODS AND RESULTS: Fifteen patients (6 m and 9 f; mean age 44 yrs) were treated for neurogenic TOS. Four patients (26.7 %) demonstrated a cervical rib. The rest did not show a diagnosable bony anomaly (73.3 %). Provocative tests were neurologically positive in all patients (100 %); 4 patients additionally demonstrated vascular symptoms (26.7 %). Six patients demonstrated ulnar nerve F-wave latency (40 %). The transaxillary approach was used in all patients. In three patients with cervical ribs (20 %), an additional ventral approach was utilized. 14 patients remain symptom-free at a mean follow-up period of 24 months (93.4 %). One complained of pain recurrence at nine months after surgery and was treated conservatively (2(1/2) yrs). One patient developed pneumothorax after surgery (6.7 %). Four patients reported on numbness of the lateral thoracic wall, due to stretch injury of the intercostobrachial nerve that lies along the approach corridor (26.7 %). CONCLUSION: The transaxillary approach is one of several described surgical options for the treatment of TOS. It lies along a natural corridor and is non-muscle splitting. Although it requires a deep surgical corridor, the transaxillary approach allows definitive treatment of both bony and soft-tissue components causing TOS, provided the anatomical boundaries are recognized and respected. A persistent cervical rib, however, calls for an additional ventral approach. The complications are minimal and the results are predominantly acceptable.

The diaphragma sellae meningioma -- a rare differential diagnosis of non-functioning pituitary adenoma.

It is important to differentiate the rare Diaphragma sellae meningioma from the quite common hormonally inactive pituitary adenoma, especially with regards to the surgical approach. The differentiation could, however, be problematic. We report the case of a 66-year-old woman with a Diaphragma sellae meningioma, which became apparent through a visual field and visual acuity disorder. Successful radical tumor extirpation was achieved via the transsphenoidal approach, since the space-occupying lesion was initially thought to be a hormonally inactive pituitary macroadenoma. However, histological investigation confirmed a meningioma. A careful retrospective analysis of the MRI revealed the possibility of a meningioma having been overlooked, since not all distinguishing features of this lesion were manifested. These criteria, as well as the principles of the surgical approach for treating sellar space-occupying lesions are discussed.