Rosati and Lord (15) added claviculectomy to anterior exploration, scalenotomy, resection of the cervical rib (when one was present), and section of the pectoralis minor and subclavian muscles as well as of the costoclavicular membrane.
The cervicoaxillary canal is divided by the first rib into two sections: the proximal one, composed of the scalene triangle and the costoclavicular space (the space bounded by the clavicle and the first rib), and the distal one, composed of the axilla.
Initial surgical therapy involves complete first rib resection, anterior scalenectomy, resection of the costoclavicular ligament, and neurolysis of C7, C8, and T1 nerve roots and the brachial plexus through a transaxillary approach (38) (Figure 5).
The major pathophysiological cause of PSS is congenital aberration of the costoclavicular ligament, which inserts far lateral to its usual insertion on the first rib.
Intermittent or partial obstruction should be treated by first rib removal through the transaxillary approach, with resection of the costoclavicular ligament medially, the first rib inferiorly, and the scalenus anticus muscle laterally.
If symptoms recurred, a first rib resection, with or without thrombectomy, was considered, as well as resection of the scalenus anticus muscle and removal of any other compressive element in the thoracic outlet, such as the costoclavicular ligament, cervical rib, or abnormal bands (55).
This reaction shows poor understanding of the underlying pathophysiology, which is the external constriction by the congenitally abnormal lateral insertion of the costoclavicular ligament.
Costoclavicular compression of the subclavian artery and vein: relation to scalenus syndrome.
Costoclavicular compression associated with cervical rib.