Surgical Outcomes Following First Rib Resection for Neurogenic Thoracic Outlet Syndrome: A Systematic Review of 1,334 Operated Sides

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Abstract Introduction Neurogenic thoracic outlet syndrome (NTOS) is the most common subtype of thoracic outlet syndrome and results from compression of the brachial plexus within the thoracic outlet. First rib resection (FRR) is considered the cornerstone of surgical management in patients with refractory symptoms, although postoperative outcomes remain variably reported. This systematic review aimed to evaluate the outcomes, complications, and recurrence rates of FRR in the management of NTOS. Methods A systematic review was conducted using Google Scholar, supplemented by artificial intelligence-assisted searches. Original studies reporting postoperative outcomes following FRR for NTOS were included. Data regarding patient characteristics, surgical approaches, postoperative outcomes, complications, and recurrence were extracted and analyzed descriptively. Comparative analyses between surgical approaches were performed using Chi-square testing. Results Nineteen studies involving 1,334 operated sides were included. Most studies were cohort studies (73.68%). Females represented 75.44% of reported patients. Successful postoperative outcomes were observed in 87.08% of analyzable cases. No statistically significant difference in success or recurrence rates was identified between the open approaches. A total of 170 complications were recorded among operated sides managed via the transaxillary approach. Pneumothorax was the most frequently reported complication in both the transaxillary (n = 99, 20.58%) and supraclavicular (n = 7, 2.68%) approaches. The overall recurrence rate was 1.50%. Conclusion First rib resection is a safe and effective surgical intervention for NTOS, yielding favorable outcomes with low recurrence across a broad range of operative approaches. Neither the choice of surgical approach nor the extent of rib resection significantly influences surgical success. Introduction Thoracic outlet syndrome (TOS) refers to a group of disorders caused by compression of neurovascular structures traversing the thoracic outlet. Depending on the affected structure, TOS is classified into neurogenic, venous, and arterial subtypes, corresponding to compression of the brachial plexus, subclavian vein, and subclavian artery, respectively [1,2]. Neurogenic thoracic outlet syndrome (NTOS) is the predominant form, accounting for approximately 90%–95% of all cases, whereas venous and arterial TOS represent approximately 3%–5% and 1%, respectively [3–5]. Neurogenic TOS is further categorized into true and disputed forms, with disputed NTOS reportedly constituting 95%–99% of neurogenic cases [6]. The estimated annual incidence of NTOS is 2–3 cases per 100,000 population, with a point prevalence of approximately 10 per 100,000 individuals [7,8]. The underlying pathophysiology most commonly involves compression of the brachial plexus, particularly the inferior trunk, which originates from the C8–T1 nerve roots, within the scalene triangle or the costoclavicular space [6]. The etiology of TOS is multifactorial and may be congenital, traumatic, or functionally acquired. Congenital causes include anatomical abnormalities such as cervical ribs and anomalous first ribs. Traumatic etiologies most commonly involve whiplash injuries and falls, whereas functionally acquired forms are associated with repetitive upper extremity activities related to occupation or athletic performance [2,6,9]. The diagnosis of NTOS remains challenging in contemporary clinical practice. No single investigation is considered diagnostic, and the condition is primarily identified through clinical evaluation based on symptomatology, provocative physical examination maneuvers, and exclusion of alternative diagnoses such as cervical radiculopathy, peripheral nerve entrapment syndromes, and other structural abnormalities [8,10,11]. Conservative management is considered the initial treatment strategy for NTOS. Physical therapy programs focusing on postural correction, ergonomic modification, and stretching of the scalene and pectoralis minor muscles are generally recommended for at least four to six months before surgical intervention is considered. Adjunctive therapies, including local anesthetic injections, corticosteroids, and botulinum toxin, are also utilized in selected patients. Surgical decompression is typically reserved for individuals who fail nonoperative treatment [6,12–14]. First rib resection (FRR) is regarded as the cornerstone of surgical management for NTOS. Several operative approaches have been described, including supraclavicular, infraclavicular, and transaxillary techniques, with the choice of approach influenced by surgeon experience and patient-specific factors. More recently, minimally invasive techniques, including thoracoscopic-assisted and robotic approaches, have also been introduced into clinical practice [12,15,16]. The aim of this systematic review was to evaluate the postoperative outcomes of FRR in the management of NTOS, with particular emphasis on surgical success, complications, recurrence, and factors that may influence clinical outcomes across different operative approaches. Methods Study design This study was conducted as a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. No prospective registration was performed prior to data collection. Search strategy A systematic literature search was conducted in Google Scholar using the keyword (first rib) with the allintitle function. This strategy was employed to maximize retrieval specificity for studies directly addressing the first rib as a primary subject. No time restriction was applied, and the search encompassed all records available up to the date of the final search (April 30, 2026). To supplement the primary database search and minimize the risk of missing relevant publications, additional searches were conducted using three artificial intelligence-based (AI-based) research tools: Consensus AI (consensus.app), Claude (Anthropic), and Perplexity AI (perplexity.ai). These platforms were queried using natural-language prompts, including "original studies reporting postoperative outcomes following first rib resection for neurogenic thoracic outlet syndrome". References identified through AI-assisted searching that were not retrieved by the primary Google Scholar search were cross-checked against the eligibility criteria and, where appropriate, retrieved in full text for screening. All records identified through AI tools were subject to the same inclusion and exclusion criteria as those identified through the primary database search. It is acknowledged that AI-assisted literature retrieval is not yet a standardized component of systematic review methodology; its use in this review was supplementary and intended to reduce retrieval bias rather than to replace conventional database searching. Eligibility criteria Studies were considered eligible for inclusion if they met the following criteria: (a) prospective or retrospective original research articles clearly reporting postoperative outcomes following FRR for NTOS; (b) studies utilizing any surgical approach or operative technique for FRR; and (c) studies reporting mixed TOS subtypes only when the data for NTOS patients were reported separately and could be extracted independently. The following records were excluded: (a) case reports; (b) studies with incomplete patient data or outcome information; (c) conference abstracts published without a full-text manuscript; (d) non-English language publications; (e) commentaries, letters to the editor, and editorial articles; (f) preprint publications; (g) studies focused on other subtypes of TOS; (h) studies reporting mixed TOS subtypes in which NTOS patients were not analyzed separately; (i) studies reporting exclusively on redo or revision surgical procedures; (j) studies in which only recurrence data were available without primary outcome re

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.