Controversies in NTOS: To Remove the First Rib or Not?

The first rib may not always require excision in NTOS. It has been shown that the pathology is in the scalene muscles (fibrosis), not in the rib. Scalenectomy alone has as good a long-term improvement rate as first rib resection, and rib resection results in more complications and morbidity. However, if when performing scalenectomy, the lower trunk of the brachial plexus is found to lie touching the first rib, it should be excised.