Thoracic outlet syndrome: which surgical approach?

Thoracic outlet syndrome (TOS) is a collection of different symptoms and disorders that affect the shoulder and upper extremity area, resulting from the compression of the neurovascular structures at the superior aperture of the thorax. The diagnosis of TOS, which includes a physical examination and clinical tests is often difficult. Indications for surgical treatment are debated and often reserved for cases which involve the failure of conservative management. The most common surgical approaches are the supraclavicular and transaxillary while minimally invasive approaches are gaining popularity. This manuscript will discuss the different approaches to the surgical treatment of TOS described over the past 50 years of surgery, focusing on the supraclavicular and the transaxillary approaches. Both techniques offer good results in expert hands, however the key to success in TOS surgery remains proper patient selection. By a supraclavicular approach it is possible to achieve an accurate diagnosis and an adequate treatment. It is safe and provides an excellent exposure of the neurovascular structures.