Scalenectomy versus first rib resection for treatment of the thoracic outlet syndrome.

Five years ago a follow-up study of first rib resections disclosed a recurrence rate of over 15%. Many patients were reexplored supraclavicularly, and in every case the anterior scalene muslce was found to be reattached to the bed of the first rib. Scalenectomy invariably was successful, which led to this study of scalenctomy as the first operation for all cases of persistent thoracic outlet syndrome (TOS). The study revealed that most patients with TOS gave a history of neck trauma and had symptoms not only of paraesthesias of the hands and weakness of the arms, but also of neck pains and headaches. The common physical findings were tenderness over the scalene muscles and duplication of symptoms with the arms raised. A scalene muslce block with a local anesthetic was the most useful diagnostic test. The good-to-excellent long-term results following 239 scalenctomies and 214 first rib resections were almost identical, 68% and 70%, respectively, with fair results in 20% and 13%, respectively. In patients with a history of neck trauma followed by headache, neck pain, arm weakness, and parasthesias in the hand, anterior and middle scalenectomy should be considered. On the other hand, first rib resection is recommended for patients with no history of neck trauma and symptoms limited to the arm and hand, particularly those patients with signs of arterial or venous insufficiency.