The place for scalenectomy and first-rib resection in thoracic outlet syndrome.

For more than a century, physicians have been seeking the elusive answers to the accurate diagnosis and reliable treatment of the thoracic outlet syndromes (TOS). From evaluation of 3630 patients for possible TOS, two distinct patterns of neurologic symptoms seem apparent, that affecting the upper roots of the brachial plexus (C5, C6, and C7) and that affecting the lower roots (CS and T1). Some patients may have both types simultaneously or sequentially. The important aspects of the history and physical examination of both types of TOS are discussed. The technique of an operation, complete anterior scalenectomy, specifically designed to relieve the upper plexus type of TOS is presented, along with the congenital anomalies that invariably seem to be associated with this syndrome. In a series of 1336 first-rib resections performed for severe TOS over the past 17 years, 92% of the operations resulted in good to excellent relief for the patient. In a series of 93 scalenectomies performed over the past 6 years specifically for upper plexus type of TOS, either primary or secondary from recurrence, every patient has obtained substantial relief.