Key Points

• For recurrent thoracic outlet syndrome, the high posterior thoracoplasty approach provides excellent exposure.
• The trapezius and rhomboid muscles are split rather than divided.
• The 1st rib remnant and fibrocartilage are removed.
• Neurolysis of C7, C8, and T1 nerve roots and the brachial plexus, as well as decompression of the axillary-subclavian artery and vein are easily accomplished through this “virgin” incision.
• Dorsal sympathectomy is added to provide optimal pain relief.

Recurrent or persistent thoracic outlet syndrome (TOS) may involve any of the neurovascular structures traversing the costoclavicular space. The great majority of recurrent TOS however, involves the sympathetic nerves and brachial plexus. The common mechanical etiology encountered during reoperation includes incomplete 1^st rib resection, growth of rib remnant, excessive scarring and intact scalene muscle. The rib remnant and the growth promoting periosteum allows osteoblasts, chrondroblasts and fibroblasts to regenerate from the end of the rib or retained bone fragments, producing a fibrocartilage that can compress the neurovascular structures. Thus, recurrent neurogenic TOS should be documented by nerve conduction studies. If the initial operation was performed through either the supraclavicular or the transaxillary approach, it may be safer to perform the reoperation through the posterior high thoracoplasty approach. This approach provides a virgin territory and allows careful neurolysis of the nerve roots and brachial plexus as well as release of the vascular structures. A dorsal sympathectomy is usually performed because the sympathetic-maintained pain syndrome and causalgia are present in most cases of recurrent thoracic outlet syndrome. Reoperation is generally indicated if conservative management has failed. [1],[2],[3]