Treatment: Minimal access surgery with no rib resection improves outcome and reduces recovery time
Animation: Differentiation of thoracic outlet syndrome into five major categories of proximal and mid-plexus disease based on imaging characteristics.Surgery for the treatment of thoracic outlet syndrome is offered by several different types of surgeons and with a wide variety of different surgical methods or approaches. A major difference is between methods directed at nerve release as opposed to methods involving resection of the first rib.
The first rib resection operation is a larger operation that often involves collapsing the lung. It is technically very challenging and should only be done by experts with a great deal of experience - it is typically offered by specialist vascular surgeons.
The major alternative is the "supraclavicular approach." This is less invasive and involves an incision above the collarbone. It is usually directed at cutting or partially resecting the anterior scalene muscle. There may also be resection of the middle scalene muscle. This approach gives a neurosurgeon or vascular surgeon a direct, precise access to each of the component nerves in the brachial plexus. In addition, other shoulder nerves that pass nearby such as the accessory nerve to the trapezius muscle and the long thoracic nerve (that is sometimes involved in pain affecting the shoulder blade) can be treated. It carries a much lower risk of major nerve, blood vessel, or lung injury.
At the Institute for Nerve Medicine, Dr. Filler has optimized the supraclavicular approach to use an incision that is about three centimeters in length. Some doctors use a much larger incision. In addition, Dr. Filler uses anti-scarring materials that greatly reduce the risk of recurrence from scar formation. In addition, Dr. Filler sometimes uses a second incision in the axilla (or underarm) to carry out nerve releases of nerves of the brachial plexus, shoulder and arm when they occur in this region. Sometimes, both incisions are needed.
Nerve release surgery for TOS is usually quite easy to recover from and is not particularly painful. Aside from the usual risks of all surgeries, thoracic outlet surgery includes special risks of injury to the phrenic nerve (that operates the diaphragm) and of the thoracic duct (that carries lymphatic digestive fluid to the bloodstream). Injuries to either of these can delay recovery but are usually not permanent problems. The open supraclavicular approach minimizes these risks when compared with first rib resection.
Dr. Aaron Filler is the world’s leading expert in treatment of nerve pain. He has revolutionized nerve-pain treatment by inventing several new technologies. One such technology, MR Neurography, enables doctors to use an MRI scanner to examine nerves — previously a difficult-to-impossible tissue to see through MR imaging. Dr. Filler's research in axonal transport is leading to a whole new generation of advanced pain medications. He has developed many new “minimal access” surgery methods that allow him to treat complex nerve problems with small outpatient surgeries. He has also pioneered the use of the Open MRI scanner to do surgeries and other therapies with the ultra-high precision and safety of the magnetic resonance imaging. 
Do You Really Need Back Surgery? by Dr. Aaron G. Filler, MD PhD, is a best-selling paperback every sufferer of spine and nerve pain should read. Written in everyday language, the book is a must-read.