Medically Challenging Cases
Outpatient Surgery Center Transaxillary First Rib Resection Mike Guzman
Community East Surgery Center
Introduction
Thoracic outlet syndrome (TOS) results from compression of the brachial plexus and/or subclavian vessels. Decompression surgery for TOS is designed to take pressure off the vessels and nerves of the arm. TOS surgical treatment is associated with significant pain and inpatient hospitalization. Effective regional anesthesia pain blocks for inpatient TOS surgery include paravertebral (1), intercostal (2), erector spinae (3), and brachial plexus (4). Technology advancements with intercostal cryoneurolysis for mastectomy (5), combined with our brachial plexus experience for inpatient TFRR convinced our vascular surgeons to proceed with 23-hour ambulatory surgery center TFRR scheduling.
Materials and Methods
Community Hospital Network policy does not require an IRB because these case reports are devoid of patient identifiable information. Patient informed consent was obtained for submission of a case report.
Results/Case Report
Three patients were scheduled for TFRR in our outpatient surgery center. Patient ages were 21-52, and ASA 3. Patients received the following regional techniques before their TFRR. Local anesthetic mixture consisted of liposomal bupivacaine 266 mg (20 ml), bupivacaine 0.25% (30 ml), and normal saline (50 ml) for a total volume of 100 ml. Patients were sedated with midazolam (3-5 mg), placed in a sitting position and received a supraclavicular block 10 ml (image 1). This was followed by a modified clavicular plane infiltration 10 ml (image 2), and infiltration 10 ml of the 2nd rib superiorly. Patients were repositioned to an operative side up, lateral position. This was followed by ultrasound guided mid axillary intercostal nerve infiltration with 10-15 ml per level T1-4 (Table 1). Cryoneurolysis of intercostal level T2-4 was then performed with a handheld cryoneurolysis device. The cryoneurolysis needle was a single needle, 90 mm long, and had a two-minute freeze cycle. Patients received endotracheal general anesthesia including propofol, rocuronium, and sevoflurane. Minimal intravenous narcotics were required in PACU. Continuous ketolorac infusions (90 mg/NS 1000 ml, 40 ml/hour), intravenous acetaminophen q 12 hours, and oxycodone 5-10 mg PO were used prn. Two patients easily met our 24 hour discharge criteria with pain scores 0-1/10. The third patient also was discharged with manageable pleurisy pain 3-4/10 because of a small (2-3 cm) incidental pneumothorax.
Discussion
TFRR is a common surgeon preference for TOS because it has a low recurrence rate and better cosmetic
outcome (1). Robotic transthoracic first rib resection may allow a more minimal invasive resection; however, it may require a hospital stay of 2-4 days (6). No single anesthesia pain block can provide pain free outcomes after TFRR due to complex sensory innervation. I previously reported significant pain reduction for TFRR with continuous brachial plexus catheters (4). More recently a combination of paravertebral and interscalene blocks was effective for post operative TOS analgesia (7). Technology advancements with intercostal cryoneurolysis similar for mastectomy in combination with liposomal bupivacaine supraclavicular block for many inpatient TFRR, readily convinced our vascular surgeons to proceed with ambulatory surgery center TFRR scheduling. Patients easily met our 24-hour discharge criteria and were released from our outpatient center. No significant motor loss or respiratory issues were observed.
References:
1. J Clin Anesth 2018 Mar,45: 4-5.doi: 10.1016/j.clinane.2017.11. 034.Epub 2017 Dec 5 T1 paravertebral catheter blocks provide opioid sparing in first rib resection for thoracic outlet.
2. Anesthesia and analgesia, 107 (1), 339-341Intercostally placed paravertebral catheterization: An alternative approach to continuous paravertebral blockade.
3. Anaesth.2022 October 19;10(2): 12190.doi: 10.1002/anr3.12190. Erector spine plane block with catheter infusion for analgesia in a patient undergoing transaxillary first rib resection.
4.American Society of Anesthesiology 2011 national meeting, abstract-Continuous brachial plexus block for first rib resection
5. American Society of Regional Anesthesia 2021 meeting, abstract 1765, Intercostal liposomal bupivacaine and percutaneous cryoneurolysis for mastectomy and reconstruction
6. SurgTechnol.2020 May 28;36:239-244 Robotic first rib resection for thoracic outlet syndrome
7. www.anesthesiologynews.com/Pain-Medicine/ Oct3,2019 A Multiple-regional-anesthesia approach-for- thoracic-outlet.
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