Minimally invasive first rib resection for symptomatic thoracic outlet syndrome: a case report.

Background: Thoracic outlet syndrome (TOS) is caused by compression of the neurovascular bundle traversing the thoracic outlet between the clavicle and first rib. Surgical decompression, most commonly via first rib resection, is indicated in select cases. Multiple surgical techniques exist, each with inherent advantages and limitations. We present a minimally invasive infraclavicular approach that enhances visualization and access to the posterior rib while optimizing protection of neurovascular structures. Case Description: A 34-year-old female presented with severe right arm pain with tingling and burning in her right hand for over a year. Symptoms were reproduced with manual compression of the costoclavicular junction and scalene triangle. Imaging demonstrated narrowing at the level of the brachial plexus with the arms abducted, which significantly widened in the neutral position. Given persistent symptoms despite conservative management, the patient underwent neurovascular decompression via a novel first rib resection. Novel components of the procedure include use of a muscle-splitting technique, three-dimensional imaging exoscope, a table-mounted retractor, optimized patient positioning, and routine neuromonitoring to improve visualization and minimize operative risks. Postoperatively, the patient experienced marked and sustained improvement in pain and paresthesia. Conclusions: This case demonstrates a novel minimally invasive infraclavicular approach to first rib resection for neurogenic TOS. These advances provide improved access to the first rib and may reduce operative risk to the patient.