The link for The Ischemic Extremity: New Findings and Treatment
By Heron E. Rodriguez, William H. Pearce, James S. T. Yao
2010
is tricky, you will probably have better luck googling it to read the details , seems it limits views by the link. Can be found on Google books.

If you look at page 500- 502 there are images & descriptions showing middle scalene removal.
So it must be possible to do it and work around the LTN issue successfully.
Quite an interesting book, lots of details on how the various TOS surgeries are done.

I guess I trust the opinion of a surgeon who actually does this sort of thing frequently more than anything I read. I saw him just last week and asked the same question. He spent ten minutes explaining that removing the *entire* median/medial scalene muscle isn't possible. Of course there are anatomical variances where the long thoracic nerve doesn't bisect the muscle in a particular person.

I guess it's more appropriate to say that it's the opinion of my surgeon (one of the premier doctors who perform many of these surgeries successfully a year) that full removal of the medial/median scalene muscle isn't done. He showed me where he clips it to avoid damaging the long thoracic nerve.

Either way it's good to know for those looking into scalene issues & surgery.
I do recall some past TOS patients (long ago) did have some LTN injury.

Thanks for the info Limoges, who is your surgeon?

Does anyone know whether the removal of the scalene muscles has been proven to better in terms of reducing recurrence, rather than cutting and moving up?

Parbie, that's a good question. My anterior scalene muscle was removed completely. 30+ years of tightness and unrelieved aching gone instantly. The medial scalene was not touched or removed because it wasn't causing problems. My surgeon was Dr. Dean Donahue (MGH/Harvard Medical School). He's as nice and humble as he is smart and skilful!

i will look for more articles about that. There is no "proven" answer. Every surgeon is different. I think the most important and hardest thing is trying to find out what is causing your problems. If it is just the cervical ribs, then you might not need anything else removed.if there are any more tests that you need to do before surgery to help decipher all of this is paramount in my opinion. You would hope that the surgeons would require this,but i have found this is not always the case. If you do come to socal,i would recommend you see dr. Jordan as he is an excellent diagnostician.

In my case, adjusting the first rib down (hooray for dr. Ando)has solved(for now) most of my scalene and shoulder muscle problems. Now i need to concentrate on the nerve issues in my arm and hand which may be bp or ulnar.

Because the approach was transaxillary, the scalenes were just cut and not removed.

Yes, I've seen numbers ranging from 10-20% of transaxillary rib resections requiring full scalenectomy surgery down the road. My scalenes were not hypertrophic so my fingers are crossed that I will not fall into this minority.

Does Dr. Donahue use the transaxillary or supraclavicular approach? I was thinking of seeing him as well, he's on vaca for a couple weeks and he also doesn't have any availabilities until end of August and I was looking to do this mid August.