Recurrence
Recurrent symptoms, primarily neurogenic, should be documented by objective NCVs. When NCVs are depressed in a patient whose symptoms are unrelieved by prolonged conservative therapy, a posterior procedure should be considered. Removal of any rib remnants or regenerated fibrocartilage and neurolysis of C7, C8, and TI nerve roots and the brachial plexus are performed. Dorsal Sympathectomy is added to minimize the contribution of causalgia to symptoms. Depo-Medrol and hyaluronic acid are employed to minimize recurrent scar.
Two distinct groups of patients require a second procedure: those with pseudorecurrence and those with true recurrence. Pseudorecurrences, typically referred from other surgeons, are never completely relieved of their symptoms after the initial procedure. They are separated into the following etiologies: mistaken resection of the second rib instead of the first, resection of the first rib with a cervical rib left in place, resection of a cervical rib with an abnormal first rib remaining, and resection of a second rib with a rudimentary first rib left. Some of these patients will have relief of symptoms after the initial procedure, but the symptoms recur 4 months to 18 years later.
The diagnosis and differential diagnosis for recurrence are similar to those for the original procedure. However, the indications for a second procedure are more stringent in that longer periods of conservative therapy are usually involved.
The preferred technique for reoperation is the posterior, high thoracoplasty, muscle-splitting incision with removal of first rib stumps, neurolysis of C7, C8, and T1 nerve roots and the brachial plexus and a dorsal sympathectomy.
Few other surgeons remove the rib completely at the initial procedure for fear of injuring T1 or C8 nerve roots. Some cover the end of the rib at the transverse process of the vertebra with scalenus medius muscle.
The primary technical factors involved in recurrence seem to be complete extirpation of the rib during the first procedure. If a rib remnant is left, osteocytes grow from the end of the bone and produce fibrocartilage and regenerated bone that compresses the nerves. The risk of fibrosis may be higher in patients who produce keloids, patients in whom hematomas are not drained, or patients who undergo early excessive physical therapy after the first surgical procedure. Occasionally other approaches have been used for a second procedure.