All-endoscopic Brachial Plexus Complete Neurolysis for Idiopathic Neurogenic Thoracic Outlet Syndrome: Surgical Technique

Neurogenic thoracic outlet syndrome is caused by a neurologic compression of the brachial plexus before it reaches the arm. Three anatomic areas are common locations for such an entrapment because of their congenital and/or acquired tightness: the interscalene triangle, the costoclavicular space, and the retropectoralis minor space. Because the compression level usually remains unknown, the treatment is still controversial and most teams focus on only one potential site. We propose an all-endoscopic technique of complete brachial plexus neurolysis that can be divided into three parts, one for each entrapment area. First, with a subacromial approach, the suprascapular nerve is released distally from the transverse ligament and then followed up to the upper trunk. Once the upper trunk is located, the middle and lower trunks are dissected in the interscalene triangle. Then, by use of an infraclavicular approach, the brachial plexus is released from the costoclavicular space by detaching the subclavian muscle from the clavicle. Finally, the pectoralis minor is released from the coracoid so that the brachial plexus is distally freed. This technique seems to be safe and reproducible, but expert knowledge of the neurovascular anatomy and advanced endoscopic skills are required.