Does the First Rib Always Need to Be Removed

The importance of first rib excision in the treatment of NTOS has been debated. It has been shown that in most patients pathology (fibrosis) exists in the scalene muscles, implying that rib entrapment may not be the underlying issue. Several reports have shown that long-term improvement rates are similar following scalenectomy alone versus first rib resection. Rib resection adds complexity to the operation and can result in injury to adjacent structures. Yet, many surgeons always remove the first rib. We propose that rib removal should be selective rather than routine, and suggest that a possible way of selecting patients needing first rib resection is to assess the proximity of the lower trunk of the brachial plexus to the first rib. We also propose that patients who are most likely to benefit from rib resection are those with a fairly straight, vertical first rib seen on preoperative chest x-ray.