Minimally invasive first rib resection for symptomatic thoracic outlet syndrome: a case report

Introduction

Thoracic outlet syndrome (TOS) was first described by Peet et al. in 1956 as symptoms caused by the compression of one or more components of the neurovascular bundle at the thoracic outlet (1). Anatomically, the thoracic outlet is the space from the supraclavicular fossa to the axilla between the clavicle and first rib (2). In addition to compression between the first rib and the clavicle, other causes of TOS include cervical ribs, pectoralis minor syndrome (PMS), and scalene muscle impingement.

TOS can be classified into three sub-types based on the primary structure most affected by compression at the thoracic outlet: neurogenic thoracic outlet syndrome (nTOS) which accounts for approximately 95% of cases; venous thoracic outlet syndrome (vTOS) representing about 4%; and arterial thoracic outlet syndrome (aTOS) which comprises roughly 1% (3). Treatment of nTOS typically begins with nonsurgical conservative management, including physical therapy, anti-inflammatory medications, and targeted injections (4). Surgical intervention is considered upon failure of conservative measures. The most common surgical treatment for nTOS is first rib resection which aims to remove the “fulcrum” against which the clavicle compresses the neurovascular bundle. Common approaches to first rib resection include transaxillary, supraclavicular, and infraclavicular approaches (5).

We describe a minimally invasive infraclavicular approach to first rib resection, scalenectomy, and neurolysis that improves visualization and access to the posterior first rib while allowing for better neurovascular protection. This approach utilizes a muscle-splitting technique with three-dimensional operative imaging via an exoscope (Synaptive VEMO^™, Synaptive, Toronto, Canada), incorporates a table-mounted retractor originally designed for cervical spine surgery (Thompson Farley, Thompson Surgical Instruments, Traverse City, MI, USA), employs a novel patient positioning to optimize the costoclavicular window, and integrates intraoperative neuromonitoring (INOM) for safety. We present this article in accordance with the CARE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-1-204/rc).

Case presentation

History

A 34-year-old female presented with 1-year history of right-sided neck and arm pain that she rated 5/10 on the Visual Analog Scale (VAS). She reported radiating tingling, burning, and cold sensations in the right arm and hand, accompanied by subjective hand weakness, rated 5/10 in severity. She reported sharp pain in the right pectoralis muscle, along with tightness, burning and spasms involving the right bicep. Conservative management, including chiropractic adjustment, massage therapy, acupuncture, and physical therapy failed to provide significant symptom relief. Despite these interventions, her symptoms progressively worsened. She had no other significant medical history. Her family history was notable for psoriatic arthritis.

Clinical examination

On neurological exam, the patient demonstrated significant tenderness and reproduction of her arm pain upon compression at the costoclavicular junction and within the scalene triangle. The reflex examination was 2+ throughout and symmetric bilaterally. Grip strength testing, assessed using a hand strength dynamometer, revealed right-sided weakness with the arms elevated (Table 1). The patient was noted to be right-hand dominant.

Imaging

Magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) were performed using the NeoVista system (Sunnyvale, CA, USA) with the arms in both abducted and neutral positions. Evaluation of the right-side demonstrated a 12-mm gap at the level of the brachial plexus with the arms abducted (Figure 1A). On the corresponding image obtained with the arms in the neutral position, this gap increased to 23 mm (Figure 1B). A 7-mm gap between the first rib and the clavicle at the level of the brachiocephalic vein was observed on the right with the arms abducted (Figure 1C). Sagittal imaging in abducted position revealed marked hypertrophy of the middle scalene muscle with narrowing of the scalene triangle. Coronal Short Tau Inversion Recovery (STIR) sequences demonstrated an approximately 8mm gap at the level of the brachial plexus with the arms abducted (Figure 1D). There was no evidence of pectoralis minor compression. Cervical spine MRI demonstrated no significant disc degeneration.

Figure 1 NeoVista MRI/MRA/MRV imaging study of the brachial plexus with the arms abducted and in neutral position. (A) Sagittal image of the right brachial plexus showing a gap of 12 mm between the first rib and the clavicle with arms abducted. (B) Sagittal image of the right brachial plexus showing a significantly widened 23 mm gap between the first rib and the clavicle with arms in the neutral position. (C) Sagittal image on the right at the level of the brachiocephalic vein showing a 7-mm gap between the first rib and the clavicle with arms abducted. (D) Coronal STIR sequences demonstrating an 8-mm gap at the level of the brachial plexus with the arms abducted. MRA, magnetic resonance angiography; MRI, magnetic resonance imaging; MRV, magnetic resonance venography; STIR, Short Tau Inversion Recovery.

Given the combination of clinical symptoms, imaging findings, and failure to improve with conservative management, surgical intervention was recommended for treatment of symptomatic nTOS. The patient underwent a right first rib resection with sectioning of the middle and anterior scalene muscles and neurolysis via a minimally invasive approach.

Surgical intervention

General anesthesia was induced with endotracheal intubation. Pre-positioning baseline motor-evoked potentials (MEPs), somatosensory-evoked potentials (SSEPs), and free-running electromyography (EMG) were obtained in all four extremities. Particular attention was given to muscle groups innervated by the C8 and T1 nerve roots and ulnar nerve distributions.

The patient was positioned supine on the Jackson Table (Mizuho|OSI, Union City, CA, USA) with the right shoulder (not arm) elevated (but not abducted) by taping the deltoid surface and putting it under tension rostrally, to open the costoclavicular space. The head was tilted away to the left (Figure 2A). AP and lateral fluoroscopy were used to identify the lateral aspect of the first rib (usually ~8 cm from midline), the medial aspect of the anterior portion of the costal margin at the costoclavicular junction (approximately 4 cm from midline). Incision planning was marked parallel to the clavicle, but 2 cm below the clavicular margin, between those two points (Figure 2B,2C). An incision was then made on the inferior edge of the right clavicle, extending from about 3–4 cm off the midline.

Figure 2 Perioperative setup and incision planning. (A) Schematic illustration demonstrating patient positioning for the infraclavicular approach. The right shoulder is elevated and stabilized using surgical tape to optimize exposure of the thoracic outlet. (B) Diagram showing the planned incision trajectory (yellow arrow) oriented parallel to the clavicle. (C) Diagram illustrating the incision orientation (red line) relative to the clavicle.

Bovie cautery was used to incise through the dermis and loose areolar tissue down to the pectoralis muscle at the junction of the clavicle and the manubrium. The pectoralis fascia was then incised at that point, beginning medially at the capsule of the claviculomanubrial junction and extending laterally approximately 2 cm. Table-mounted radiolucent retractor blades were positioned to separate and spread the fibers of the pectoralis major muscle, exposing the underlying first rib (Figure 3A,3B).

Figure 3 Intraoperative visualization and retractor placement. (A) Schematic illustration highlighting placement of the table-mounted retractors to expose the operative field during the infraclavicular approach. The relationship between the clavicle, first rib, second rib, and underlying neurovascular structures is shown. (B) Intraoperative anterior-posterior radiograph demonstrating right-sided placement of the cervical retractors directed toward the first rib.

The exoscope was then brought into the field and oriented medially (Figure 4). The pectoralis major muscle fibers were dissected off the first rib using low-power Bovie cautery and further retracted caudally. A subperiosteal dissection was then carried out along the dorsal surface of the first rib toward the cartilage of the costo-manubrial junction, allowing clear identification of the medial rib insertion.

Figure 4 Intraoperative photograph demonstrating the operating surgeon utilizing a three-dimensional exoscope system.

A longer (50 mm) retractor blade was then placed beneath the clavicle, resting on the dorsal surface of the first rib, and used to dissect posteriorly toward the insertion of the anterior scalene muscle. Using the ClearView (Midas Rex Clearview^™, Medtronic, Memphis, TN, USA) drill with a 3-mm diamond bit, the medial tip of the first rib was drilled to expose the costo-manubrial cartilage. Once visualized, the endothoracic fascia was carefully dissected off the dorsal rib surface and separated laterally, freeing its attachments to the clavicle rostrally and the intercostal muscles caudally. Dissection proceeded along the ventral/dorsal surface of the rib in a lateral direction. This allowed separation of the first intercostal muscles from the caudal surface of the first rib, as well as detachment of the anterior and then middle scalene muscles. The table mounted retractor blade was advanced further posteriorly beneath the clavicle over the first rib, gently depressing the first rib down.

As the dissection moved posteriorly over the first rib, the 50 mm retractor blade was replaced by a 70-mm blade. This provided protection of the mobilized neurovascular bundle and facilitated its separation from the first rib. The remaining portion of the first rib was gently depressed slightly into the chest cavity, taking care not to violate the endothoracic fascia or the parietal pleura (Figure 5).

Figure 5 Intraoperative exposure of the first rib highlighting the posterior aspect of the rib. ETF, endothoracic fascia.

Care was taken to avoid injury to any arterial, venous, or neural structures. The posterior scalene muscles were visualized past the retractor tip. The ClearView 3 mm diamond bit was then used to drill through the entire thickness of the first rib (Figure 6A,6B). Once completely detached, the rib segment, measuring about 7.5 cm in length, was successfully removed (Figure 6C).

Figure 6 Intraoperative exposure and resection of the first rib. (A) Intraoperative view demonstrating retraction and exposure of the first rib. (B) Use of the ClearView 3 mm diamond drill to perform resection of the first rib. (C) En-bloc resection specimen of the first rib measuring 7.5 cm in length.

There was no evidence of tear of endothoracic fascia (ETF) tear or air leak. Estimated blood loss for the procedure was approximately 15 cc. The muscle was allowed to fall back into place, and the fascial incision was closed with #1 Vicryl™ (Ethicon, Johnson & Johnson, Raritan, NJ, USA) sutures, and then the skin closed in a multi-layered fashion with 3-0 interrupted Vicryl™ sutures. There was no change in potentials from the baselines. The patient was injected with 20 cc of Exparel™ (Pacira BioScience, Parsippany, NJ, USA) for pain control and awoken from anesthesia. She was placed in an arm sling in the post-anesthesia care unit and discharged home the next day. After 2 weeks, she was taken out of the sling and began gradual range of motion.

Postoperative course

At the 1-month follow-up, the patient reported significant improvement in symptoms, with a reduction in pain to a 3/10 on the VAS. The patient had residual numbness and tingling in the right hand, rating it a 4/10 in severity. At 1-year follow-up, the patient continued to report a VAS pain score of a 3/10 and had continued improvement of numbness and tingling with reduced frequency of episodes. At the 2-year follow-up, the patient reported decreased pain, reporting a 2/10, with further improvement in numbness and tingling, rating it a 1/10 in severity. Grip strength dynamometer testing conducted at the 2-year follow-up demonstrated improvement in the right arm strength, as shown in Table 2.

Ethical statement

All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Advarra’s Review Board (No. (CIRBI) 0000635). Written informed consent was obtained from the patient for publication of this case report and accompany images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

We present a minimally invasive infraclavicular first rib resection for symptomatic nTOS. First rib resection is a safe and effective treatment for TOS, although complication rates vary by approach (6-8). Reported risks include pneumothorax, vascular injuries, and brachial plexus damage (8,9). While Cheng et al. found longer hospital stays with rib resection compared to scalenectomy alone, other studies demonstrate no significant differences in complications between procedures with and without first rib resection (8,10).

Surgical approaches to first rib resection

Each approach to first rib resection offers distinct advantages and limitations. The transaxillary approach, commonly used by vascular and thoracic surgeons, avoids pectoralis muscle dissection and offers cosmetic benefits. The transaxillary approach has been associated with shorter operative time and length of stay compared to the supraclavicular approach (11). However, it has a relatively higher complication rate, requiring manipulation in a deep, narrow surgical field (5,9).

The supraclavicular approach provides more direct visualization and manipulation of the neurovascular structures in a shallow field, facilitating a more direct approach for procedures such as isolated scalenectomy. Its main limitation is limited anterior rib access within the costoclavicular space (5).

The infraclavicular approach improves visualization and access to the anterior structures and is associated with lower reported complication rates, but posterior rib access can be difficult (6,12).

The posterior approach avoids many high-risk structures and is useful for patients with prior anterior surgical history requiring reoperation. However, it offers limited anterior visualization and carries potential risks such as cervical or scapular instability (5).

Robotic trans-thoracic rib resection has been proposed as a technique that minimizes retraction of neurovascular structures (13). However, the neurovascular bundle is only visualized after removal of the rib, making protection of the neurovascular bundle more challenging.

Recurrent TOS

Recurrent TOS has been attributed to residual anterior or posterior rib segments, though definitions of recurrent TOS vary (14-17). Likes et al. define recurrence as return of nTOS symptoms after prior rib resection with persistent anterior or posterior first rib segments on chest X-ray (15). In contrast, others advocate for a more comprehensive diagnostic evaluation, including computed tomography (CT), EMG, and diagnostic scalene blocks to confirm the etiology of persistent or recurrent symptoms (16,17). Most recurrence data derive from transaxillary and supraclavicular series, and recurrence after infraclavicular approaches remains less clearly characterized. Distinguishing true recurrent TOS from an incorrect initial diagnosis or from persistent symptoms related to intraoperative injury is essential for appropriate management. Our technique incorporates modifications intended to facilitate a more complete resection beyond potential points of impingement.

Technical considerations

Our minimally invasive technique for the infraclavicular approach to first rib resection incorporates five key refinements: (I) we utilized a 3–4 cm muscle-splitting incision; (II) aided by the magnification and angulation of the three-dimensional operating exoscope; (III) use of table-mounted retractor blades; (IV) assisted by taping the shoulder up but with the arm down; and (V) the use of INOM for prevention of neurological retraction injury.

Exposure

We utilize a 3–4 cm incision through which the muscle fibers are split rather than transected, creating a muscle-sparing approach to reduce tissue disruption and potentially accelerate recovery. This approach complements evolving advancements in minimally invasive first rib resection, including endoscopic-assisted, video-assisted thoracoscopic surgery (VATS), and robotic techniques (13,18). Carter et al. recently described a single-port endoscopic transaxillary approach using a smaller incision to minimize wound morbidity and post-operative pain (18).

Three-dimensional exoscope

The three-dimensional exoscope may offer advantages over previously reported endoscopic-assisted infraclavicular approaches (19). While endoscopic-assisted techniques may enable smaller incisions, they often require fixed, ergonomically challenging positioning and provide a limited, two-dimensional, or otherwise restricted field of view (18).

Augmented reality-assisted endoscopic infraclavicular first rib resection has also been described, with reported improvements in visualization in major vessels and the extent of resection (20). However, augmented reality systems introduce additional limitations, including potential positional deviation errors and accuracy risks, while retaining the core positional constraints inherent to endoscopic approaches.

In contrast, the three-dimensional exoscope provides high-resolution, magnified, deep-focus visualization which may facilitate identification of complex anatomy while reducing surgeon fatigue. Reports describing three-dimensional exoscope-assisted first rib resection in TOS remains limited. In spine surgery, reported advantages include increased working distance, improved surgeon posture, and enhanced trainee education (21). Potential limitations include increased operative time, equipment and maintenance costs, limited long-term outcomes data, and the possibility that certain techniques may be better suited to an operating microscope or endoscope (14).

Table-mounted retractor

The table-mounted Thompson-Farley cervical retractor blades enhance visualization of the posterior rib by gently depressing it into the thoracic cavity away from the brachial plexus, preventing pressure on the neurovascular bundle while providing stable retraction to facilitate more complete resection.

Positioning

Visualization and access to the first rib are influenced by patient positioning. In our technique, clavicular elevation is achieved by taping the ipsilateral deltoid region under pressure to the rostral end of the table, which opens the thoracic outlet without compressing the neurovascular structures. This provides stable exposure without the need for intraoperative adjustment. To our knowledge, this positioning maneuver has not been previously described for infraclavicular first rib resection (22-24).

INOM

Routine IONM, particularly ulnar nerve SSEPs, MEPs and EMG, may help protect the brachial plexus during resection. In our approach, monitoring focused on the ulnar nerve and C8 distribution. Published reports describing the routine neuromonitoring during first rib resection remain limited.

Limitations

This report describes a single case without comparison to conventional approaches, limiting generalizability.

Conclusions

We describe a minimally invasive infraclavicular first rib resection employing several technical refinements we believe enhance the safety and efficacy of the procedure. Reduced disruption to the pectoralis muscle may support earlier mobilization and decreased postoperative pain. The operating exoscope offers enhanced visualization in a confined space and surgically awkward angle, enabling more completely posterior rib resection. Use of a table-mounted retractor enhances precision and safety by protecting neurovascular structures and limiting tissue injury. Shoulder elevation via taping to the table helps optimize thoracic outlet access without compression. The patient’s clinical improvement supports this approach as a promising option for nTOS. Larger series are required to determine whether these technical refinements translate into improved clinical outcomes.

Acknowledgments

We would like to acknowledge the use of Complete Anatomy software in the creation of the original anatomical illustrations included in this manuscript.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-2025-1-204/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-2025-1-204/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-1-204/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Advarra’s Review Board [No. (CIRBI) 0000635]. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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