Supraclavicular radical scalenectomy and transaxillary first rib resection for the thoracic outlet syndrome. A combined approach.

Transaxillary resection of the first rib alone was performed 97 times to relieve symptoms of irritation of the brachial plexus. Persistent or recurrent symptoms occurred in a fifth of the patients (7 and 13 patients, respectively), and necessitated reoperation using the supraclavicular approach. In all patients, at least one anomaly or acquired deformity was found that could not have been identified or safely removed by the original transaxillary approach alone. Subsequently, 94 combined operations, including supraclavicular radical scalenectomy with neurolysis of the brachial plexus and transaxillary resection of the first rib, were performed for irritation of the brachial plexus. The improved results using the combined procedure has led us to recommend it for the majority of symptomatic patients with irritation of the brachial plexus. The combined approach allows precise assessment of the thoracic outlet anatomy, facilitates first and cervical rib resection, and permits removal of any additional congenital or acquired lesions. It is associated with a low failure rate and results in few postoperative complications. However, the transaxillary approach alone may be suited for the patient with localized lower plexus symptomatology, keeping in mind the risk of recurrent symptoms associated with this technique.