Reserving supraclavicular first rib resection for vascular complications of thoracic outlet syndrome

Background The traditional approach to decompression of the thoracic outlet has been by transaxillary resection of the first rib. Recently, the trend has been toward a more selective and tailored surgical approach via the supraclavicular route. Methods During a 51-month period, 14 consecutive patients underwent decompressive surgery of the thoracic outlet via the supraclavicular approach. There were ten women and four men; mean age was 44 years. Indications for operation were arterial (n=3), venous (n=2) and neurogenic (n=9). Mean follow-up was 31 months. Operation consisted of resection of the anterior scalene and medial aspect of the middle scalene muscles and brachial plexus neurolysis for neurogenic indication, with first rib resection reserved for vascular complications. Results Operations performed for vascular complication were successful and uncomplicated, with good clinical outcome. Seven of nine operations (78%) performed for neurogenic indication produced marked relief of symptoms, while two (22%) resulted in no clinical change. Complications consisted of transient scapular winging (n=1) and transient diaphragmatic paralysis (n=2). Conclusions A selective approach to thoracic outlet decompression, consisting of anterior scalenectomy and brachial plexus neurolysis for neurogenic symptoms, and reserving first rib resection for arterial and venous indications, is a safe procedure and yields satisfactory results in appropriately selected patients.