In my case (true neurogenic TOS), in addition to a L first rib resection, Drs. Ahn and Annest both proposed neurolysis of the C-8 and T-1 nerve roots plus the lower trunk of the brachial plexus, as well as lysis of the subclavian vessels (artery and vein), using the transaxillary approach. The latter performed my decompression surgery in 2005 and these procedures are a part of the surgical report.

The question of access to and adequate visualization of the brachial plexus was not an issue by virtue of the method of surgical approach in my case. But I understand your point, and I do recall reading in the literature that a supraclavicular approach is touted by some TOS surgeons as affording more direct visualization and/or access to the neurovascular bundle.

On the other hand, there is an argument that full excision of the first rib is more easily achieved using the transaxillary approach, so maybe it's a trade-off. There seem to be valid arguments to each approach; I think it is largely a matter of the surgeon's preference as well as the particulars of each individual case (i.e., whether the compression is largely soft tissue or bony [or both]). I've even heard of at least one case where the TOS patient was given a choice between the two approaches (although the surgeon seems to have gone in both over the collarbone and under the arm during the actual operation, unbeknownst to that patient [!]).

As far as I know, regardless of the surgical approach, lysis and neurolysis of the affected vessels and nerves are fairly standard practices, not only in the initial TOS surgery but in any subsequent "re-do" surgery as well, as scar tissue builds up and compresses these structures in the thoracic outlet.

Just my 2 cents on this, based on my own research (9 years ago now) and personal experience with TOS surgery…

But you've got me curious about something. Does anyone know whether Annest has since changed his approach preference now that he is partnered with Dr. Sanders (who mostly performed supraclavicularly as he primarily did scalenectomies when he was active as a surgeon, unless he saw specific rib involvement once he was "in"), or vice versa?

If so, do they vary it case by case (based on testing and clinical findings), to individualize it to each new surgical TOS candidate presented to their office?