First rib resection for thoracic outlet decompression remains a controversial solution to a complex problem. The term thoracic outlet syndrome refers to a variety of symptoms usually neurologic but is on occasion vascular and that results from any of a number of anatomic situations. Most patients with thoracic outlet syndrome improve significantly with physical therapy and repetitive behavior avoidance. Only a small number of patients require surgical intervention. When such intervention is indicated, resection of the first rib is the most common approach, but is not the only possible procedure. Some authors recommend subperiosteal resection of the first rib in order to reduce the risk for injury to the neurovascular contents; however, leaving the periosteum intact can lead to reformation of a rudimentary rib, which can cause recurrence of the symptoms. In this chapter, complete resection of the first rib and its periosteum is described. For further discussion of the etiology and treatment of this complex condition, the reader is referred to the references. This uncommon procedure is included because it illustrates regional anatomy well.

The brachial plexus and subclavian artery pass between the anterior and middle scalene muscles, the subclavian vein passes between the anterior scalene muscle and the first rib (Fig. 31.1). Any of these three crucial structures are vulnerable to compression. Unfortunately, simple excision of the anterior scalene muscle generally fails to solve the problem and the wider decompression afforded by first rib resection is generally required.