Rib-Sparing Anterior Scalenectomy Versus First Rib Resection for the Treatment of Thoracic Outlet Syndrome.

Background and objectives: Thoracic outlet syndrome is a group of disorders resulting from dynamic compression of the brachial plexus, subclavian artery, and/or subclavian vein. Patients who experience progressive symptoms despite conservative measures may benefit from surgical decompression, which is most commonly performed via first rib resection or resection of the anterior scalene muscle. Prior studies have suggested lower morbidity associated with rib-sparing scalenectomy, although few direct comparisons exist.

Methods: Retrospective cohort study of all patients undergoing first-time thoracic outlet decompression at our institution. Patients were divided into 2 cohorts: those who underwent first rib resection by any of 4 approaches and those undergoing rib-sparing anterior scalenectomy. Paired t-tests and the χ2 test were used to compare baseline comorbidities, rates of perioperative complications, and pain relief at 90-day follow-up. We hypothesized that the rates of complications would be higher in those undergoing first rib resection.

Results: A total of 191 patients met eligibility criteria, 112 who underwent rib-sparing anterior scalenectomy, and 79 who underwent first rib excision. Anterior scalenectomy procedures were associated with greater odds of transient phrenic nerve palsy. First rib resection was associated with higher rates of pleural injury, postoperative pneumothorax, nerve transection injuries, and vascular injuries. The rate of any complication was higher in first rib resection compared with anterior scalenectomy (53.2% vs 8.9%, P < .01), a finding which persisted on a subgroup analysis comparing supraclavicular rib resection to anterior scalenectomy. Rates of future redo thoracic outlet decompression were similar between groups.

Conclusion: First rib resection is associated with higher rates of complications compared with rib-sparing anterior scalenectomy, driven primarily by pleural injury and nerve injuries.