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NTOS Surgical Approaches

Supraclavicular incision


(above clavicle)

Transaxillary incision


(through the armpit)

The two main surgical approaches used for NTOS are Supraclavicular and Transaxillary.  Which approach is used typically depends on surgeon preference, what they were trained in, and what they are most comfortable with.  From a safety standpoint, both approaches can be used safely as long as the surgeon is properly trained in both the surgery itself and the chosen approach.  Highly experienced TOS experts who are trained in both approaches might choose one or the other depending on a patient’s circumstances.  TOS experts have stated pros and cons of each approach depending on which they prefer. Keep in mind that these experts have differing opinions about the pros and cons of both approaches.  Below is a summary of the various pros and cons.



  • Ease of removal of posterior portion of first rib

  • Easy access to any cervical rib for complete removal

  • Complete removal of both anterior & middle scalene muscles

  • Complete neurolysis of all 5 brachial plexus nerve roots

  • Ability to wrap all nerve roots to help prevent post-op scar tissue

  • Best view of brachial plexus nerves to prevent injury to the same

  • Best view of surgical area for identifying & removing any fibrous bands or other anomalous structures

  • Ability to address any unexpected arterial findings such as dilatation or aneurysm

  • Ease of management of any intraoperative bleeding complications (although rare)

  • More vascular surgeon familiarity of surgical approach as it’s used for other vascular surgery conditions


  • Inability to remove the entire first rib

  • More manipulation of the nerves

  • Higher incidence of phrenic nerve injury

  • Higher incidence of thoracic duct lymph leak

  • Longer operating time

  • Longer hospital stay

  • Less cosmetically appealing scar



  • Ability to remove the entire first rib

  • Ability to work beneath the brachial plexus nerves to prevent injury to the same

  • Lower incidence of phrenic nerve injury

  • Lower incidence of thoracic duct lymph leak

  • Shorter operating time

  • Shorter hospital stay

  • Cosmetically appealing scar


  • Inability to completely remove anterior & middle scalene muscles (only about 25% of the muscles can be removed)

  • Inability to remove fibrous bands from upper brachial plexus

  • Only able to perform neurolysis on the lower 2-3 nerve roots

  • Inability to wrap nerve roots to prevent post-op scar tissue

  • Not as easy to remove posterior portion of first rib

  • Not as easy to completely remove any cervical rib

  • Unable to perform any repair or reconstruction of the artery if unexpected findings of dilatation or aneurysm without patient repositioning and additional incision(s)

  • More difficult management of intraoperative bleeding complication (although rare)

  • less surgeon familiarity with anatomy via this approach


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