Controversies in NTOS: Transaxillary or supraclavicula first rib resection in NTOS?

Abstract

Most believe that proper treatment of neurogenic thoracic outlet syndrome (NTOS) requires excision of the first rib and adequate scalenectomy. The supraclavicular approach allows most thorough scalene muscle excision and brachial plexus neurolysis, while the transaxillary approach is most cosmetic and seems to decompress the thoracic outlet very nicely. Large series utilizing either approach show excellent and equivalent results. I believe that the patient with upper plexus symptoms, cervical tenderness, a broad bony cervical rib and/or a history of trauma is best treated by supraclavicular first rib excision. By contrast, those patients with clear-cut lower plexus (ulnar nerve) symptoms in the absence of trauma should be offered transaxillary resection.