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Abstract
Please confirm that an ethics committee approval has been applied for or granted: Not relevant
Background and Aims Thoracic outlet syndrome (TOS) is a rare condition characterized by compression of neurovascular structures in the thoracic outlet. Surgical decompression is indicated when conservative treatments fail. This study compares the efficacy and safety of regional anaesthesia (RA) combined with spontaneous breathing versus general anaesthesia (GA) for TOS surgery (figure 1).
Methods A retrospective comparative study was conducted on 68 patients undergoing trans-axillary first rib resection for TOS. Patients were divided into GA (29) and RA (39) groups. RA involved supraclavicular brachial plexus (SBP) (figure 1) and pectoral nerves (PECS II) blocks with deep sedation. Pain scores, opioid consumption, and perioperative outcomes were analyzed.
Results Postoperative pain was significantly lower in the RA group in the recovery room (median NRS 0 vs. 2, p = 0.0443) (figure 2). Intraoperative fentanil and remifentanil consumption were significantly lower in the RA group (96.15 ± 62.18 mcg vs 312.07 ± 92.24 mcg and 73.13 ± 132.75 mcg vs 390.57 ± 390.71 mcg, respectively; p< 0.05). Postoperative morphine was required only by 18% of patients in the RA group (vs. 55% in GA group). RA was associated with shorter surgical times and reduced nausea and/or vomiting. Moreover, in RA group fewer intraoperative lung injuries occurred due to lung collapse during spontaneous breathing (0% vs. 41%; p < 0.001) (figure 3). Length of hospital stay was also shorter in the RA group.
Supraclavicular Brachial Plexus block. The presence of a supernumerary rib alters the normal anatomy and sono-anatomy, making easier a medial-to-lateral approach. BP= brachial plexus; SR=supernumerary rib; SA: subclavian artery; EN: echogenic needle
Postoperative pain scores The box plot shows postoperative pain scores in GA and RA groups. Data include pain reported at four different postoperative time-points (RR, 6, 12 and 24 hours). A 0-10 Numeric Rating Sale (NRS) has been used to express pain, with 0 equal to no pain and 10 = the worst imaginable pain. Values are expressed as median (horizontal bars) with 25th–75th (box) and range of minimum to maximum value (whiskers). RR=recovery room; GA=general anaesthesia; RA= regional anaesthesia
Intraoperative view of the first rib dissection Collapsed lung following surgical pneumothorax facilitated surgical maneuvers
Conclusions RA combined to spontaneous breathing significantly reduced opioid consumption and surgical times, facilitating surgical maneuvers and decreasing complications, compared to GA. Further studies are warranted to validate these findings.