If nonsurgical treatments do not relieve a person’s thoracic outlet syndrome symptoms, a doctor may suggest surgery to relieve compression in the thoracic outlet. Surgery may include a first rib resection or balloon angioplasty.

Thoracic outlet syndrome (TOS) is a group of disorders that involve compression of the arteries, nerves, and blood vessels in the space between the first rib and collarbone, called the thoracic outlet.

TOS may cause pain, weakness, and numbness and can affect a person’s range of motion. Treatment typically involves medication, physical therapy, or both. It does not usually require surgery. However, if nonsurgical treatment is unsuccessful, a doctor may suggest surgery.

There are several approaches to TOS surgery. A person’s doctor may discuss the advantages and disadvantages of each, as well as their probable outcomes.

A doctor speaking with someone in a hospital bed before a thoracic outlet procedure.-2Share on Pinterest
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Surgery is not typically a first-line treatment for TOS. A doctor may recommend decompression surgery if physical therapy and medication do not improve a person’s symptoms within 4 to 6 months.

The most common surgical procedures to treat TOS are a first rib resection and a scalenectomy or scalenotomy. These involve a surgeon removing part of the first rib and removing or severing the scalene muscles between the neck and chest.

The surgery aims to reduce compression on a group of nerves called the brachial plexus.

Transaxillary surgery

This is the most common approach to first rib removal.

The surgeon creates an incision between the pectoralis major — the large, fan-shaped muscle extending across the chest — and the latissimus dorsi muscle extending from the middle to the lower back.

They then dissect the front and middle scalene muscles and remove the first rib.

Supraclavicular surgery

In this approach, a surgeon makes an incision 1 to 2 centimeters (cm) above the collarbone and then removes the front and middle scalene muscles and a portion of the first rib.

Infraclavicular surgery

This is the least common approach to rib resection.

A surgeon makes an incision 1 cm to 2 cm below the collarbone. They may remove portions of specific muscles, ligaments, and the first rib to reduce compression on a deep vein called the subclavian vein.

Robotic and thoracoscopically assisted surgeries

More recent procedures for TOS include robotic and thoracoscopically assisted surgeries.

In these surgeries, doctors create several incisions, or portals. Surgeons insert a thoracoscope, which is a thin, flexible tube with a light and camera on the end, into the fifth space between the ribs to view the area.

Surgeons may use a robotic assistance device guided by the image from the thoracoscope to remove a portion of the first rib and some of the surrounding muscles.

Balloon angioplasty or venoplasty

A person with venous TOS may require surgery to widen narrow arteries or veins after a first rib resection.

For these procedures, a surgeon inserts a catheter attached to an inflatable balloon into the arm through an artery (during an angioplasty) or a vein (during a venoplasty). They then guide the catheter into the thoracic outlet and inflate the balloon.

The preparation for TOS surgery may involve:

  • undergoing imaging tests, such as:
  • following instructions from the doctor about when to stop eating and drinking
  • taking medication only according to the doctor’s advice
  • planning ahead to spend 1 to 2 days in the hospital

The transaxillary, supraclavicular, infraclavicular, and robotic and thoracoscopically assisted surgeries all aim to relieve compression in the thoracic outlet.

In each of these surgical approaches, surgeons remove a portion of the first rib and sometimes the scalene muscles and other nearby muscles.

The surgery relieves pressure on the nerves and blood vessels, which can improve symptoms like pain, numbness, and weakness.

The major differences between each approach are the areas of incision. Where the surgeons make their incisions can affect their ease of access to the thoracic outlet. This may affect the level of complexity of the surgery, the cosmetic appearance afterward, and the overall outcome.

For a balloon angioplasty or venoplasty, the surgeons aim to widen arteries or veins that may have narrowed due to venous TOS.

In this condition, the subclavian vein may travel through a narrow space in the thoracic outlet, which can lead to blood clots and obstructions. The surgery helps widen affected veins or arteries in the arms or chest.

Recovery for first rib resection procedures is generally fast.

Although the speed of recovery can differ depending on a person’s overall health and other factors, people can usually leave the hospital 1 to 2 days after surgery.

A healthcare professional may instruct people on movement and breathing exercises to perform during recovery. These can help prevent blood clots and clear the lungs.

A person can usually go home within a few hours of a balloon angioplasty or venoplasty and return to their usual activities within a week.

A healthcare professional may also prescribe pain medication and advise a person on caring for their incision wounds at home.

Researchers in a long-term 2021 study suggest that 80% to 90% of people reported minor or no residual TOS symptoms as long as 15 years after first rib resection surgery.

However, other researchers have reported less favorable rates of success.

The National Library of Medicine cites a study that found the success rates of decompression surgery for TOS were between 50% and 75%. A separate study found that 72.5% of people reported work disability within 4.8 years of TOS surgery.

Doctors routinely advise against major surgery to treat TOS due to the potential for complications.

Risks of first rib resection include:

Risks of angioplasty include:

  • bruising and bleeding
  • blood clots
  • narrowing of the artery

What is the best treatment for thoracic outlet syndrome?

Treatment for TOS usually involves physical therapy to strengthen muscles and improve posture and nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce swelling and pain.

How risky is thoracic outlet surgery?

Researchers do not associate first rib resection with higher-than-normal surgical or medical risks.

Angioplasty is a low risk procedure, and complications are rare.

How painful is thoracic outlet surgery?

People may experience different levels of pain and discomfort after decompression surgery. Healthcare professionals can provide medication intravenously or orally to help manage pain.

Thoracic outlet syndrome (TOS) refers to several conditions that involve compression in an area of the chest called the thoracic outlet.

Treatment for TOS typically involves physical therapy and medication. If nonsurgical treatment does not work, a doctor may recommend surgery.

Surgery for TOS usually involves removing a part of the first rib and sometimes some nearby muscle to relieve compression.