A modified supraclavicular approach to scalenotomy without first rib resection for the treatment of neurogenic thoracic outlet syndrome

Background: Current approaches to scalenectomy for brachial plexus decompression can cause nerve injuries in patients with neurogenic thoracic outlet syndrome (nTOS), especially when first rib resection (FRR) is performed. We describe a modified supraclavicular approach for scalenotomy that reduces the postoperative morbidity of nTOS patients. Methods: The patient is placed in supine position with the neck slightly extended and turned to the opposite side of the procedure. The modified incision begins above the clavicle 2.5 cm lateral to its first third, extends in medial direction, and turns upwards along the lateral edge of the sternocleidomastoid muscle (SCM) 2.5 cm from the clavicle. Skin flaps are elevated. The external jugular vein is dissected and retracted. The supraclavicular nerves and omohyoid muscle are conserved if found. The phrenic nerve is identified, dissected, and retracted. The anterior scalene muscle is divided, and the brachial plexus is freed. The clinical data and postoperative outcomes of patients that underwent surgery over the last three years were retrieved. The functionality of the arm after surgery was evaluated using the Disabilities of the Arm, Shoulder, and Hand questionnaire in Spanish (DASHe). Results: Sixteen nTOS patients received surgery with one bilateral procedure (17 procedures). Seventy-five percent were females with a median age of 53 years. Obesity and smoking were observed in 43.75% and 37.5% of patients, respectively. No postoperative complications occurred, except for one partial phrenic nerve palsy. All patients reduced their DASHe scores after surgery (mean reduction 41.09 ± 18.37). Conclusion: Our modified supraclavicular approach for scalenotomy is safe and improves outcomes in patients with nTOS, reducing the need for FRR.