Supraclavicular Approach to First Rib Resection for Thoracic Outlet Syndrome

Loupe magnification ([times]4.5) and microbipolar cautery are used, and a portable nerve stimulator (Concept 2, Clearwater, FL) is frequently applied throughout the procedure. A sandbag is placed between the scapulae and the neck extended to the nonoperative side. Long-acting paralytic agents are avoided. An incision is made in the supraclavicular fossa, in a neck crease parallel to and 2 cm above the clavicle.

The supraclavicular nerves are identified just beneath the platysma and mobilized to allow vessel loop retraction.

The omohyoid is divided and the supraclavicular fat pad is elevated, after which the scalene muscles and the brachial plexus are easily palpated. The lateral portion of the clavicular head of the sternocleidomastoid is divided and at the end of the procedure is repaired. The phrenic nerve is seen on the anterior surface of the anterior scalene muscle; the brachial plexus is noted at the interscalene position, and the long thoracic nerve is noted on the posterior aspect of the middle scalene muscle.

The anterior scalene muscle is divided from the first rib, and the subclavian artery is noted immediately behind this. An umbilical tape is placed around the subclavian artery. The phrenic nerve is not mobilized, but rather is protected by direct visualization, while the anterior scalene muscle is divided.

The upper, middle, and lower trunks of the brachial plexus are easily visualized and gently mobilized. The middle scalene muscle is now divided from the first rib. It has a broad attachment to the first rib, and care must be taken to avoid injury to the long thoracic nerve, which in this position may have multiple branches and may pass through or posterior to the middle scalene muscle.

With division of the middle scalene muscle, the brachial plexus is easily visualized and mobilized, and the lower trunk is identified with the C8 and T1 nerve roots resting above and below the first rib, respectively. Congenital bands and thickening in Sibson’s fascia are divided.

The first rib is then encircled and divided where it is easily visible with bone-cutting instruments. Note the relationship of the C8 and T1 nerve roots with the head of the first rib. These roots are reflected and protected to allow maximum exposure of the first rib.

With the nerve roots reflected anteriorly, the posterior segment of the divided first rib is removed back to its spinal attachments by rongeur technique. By using a fine elevator, the soft-tissue attachments to the first rib are separated. The posterior edge of the first rib is grasped firmly with a rongeur, and a rocking and twisting motion is used to remove the entire aspect of the rib. This technique facilitates removal of the entire posterior portion of the rib to ensure residual bone does not remain, thereby preventing new bone formation and the potential for production of recurrent compression.

With the posterior segment of the first rib removed in this fashion, the cartilaginous components of its articular facets with both the costovertebral and the costotransverse joints can be identified on the specimen. The anterior portion of the first rib is removed in a similar fashion to decompress the neurovascular elements. Cervical ribs or long transverse processes are removed by the same technique.

Complete decompression of the neurovascular elements of the brachial plexus is now confirmed. The brachial plexus, subclavian artery, phrenic nerve, and long thoracic nerve have been protected. We use a technique described by Nelems to open the pleura, facilitating drainage of any postoperative blood collection into the chest cavity rather than allowing the blood to collect in the operative site around the brachial plexus. When opening the pleura, care is taken to protect the intercostal brachial nerve, which is noted on the dome of the pleura. Bupivacaine (Marcaine, Hospira Health Care Corporation, Saint-Laurent, Quebec, Canada) is injected into the wound for postoperative comfort and a bupivacaine-filled pain pump (I-Flow Corporation, Lake Forest, CA) is also utilized. The sternocleidomastoid muscle is repaired; the wound is closed in a subcuticular fashion over a simple suction drain, and the drain is sealed after maximal inflation of the lungs by the anesthetist.

Postoperatively, gentle range of motion exercises are started on the first postoperative day and the drain and pain pump are removed on the second or third postoperative day. Supervised physiotherapy is started 2 weeks after surgery.