Thoracic outlet syndrome for thoracic surgeons Bryan M. Burt, MD  The Journal of Thoracic and Cardiovascular Surgery  Volume 156, Issue 3, Pages 1318-1323.e1 (September 2018) DOI: 10.1016/j.jtcvs.2018.02.096 Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 A model for a multidisciplinary team approach to thoracic outlet syndrome. PMR, Physical medicine and rehabilitation. (Published with permission from the Michael E. DeBakey Department of Surgery at Baylor College of Medicine Houston, Tex.) The Journal of Thoracic and Cardiovascular Surgery 2018 156, 1318-1323.e1DOI: (10.1016/j.jtcvs.2018.02.096) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 The Baylor College of Medicine thoracic surgery diagnostic and therapeutic algorithm for neurogenic thoracic outlet syndrome (TOS). Every new patient with suspected neurogenic thoracic outlet syndrome is seen by a thoracic surgeon and a physical medicine and rehabilitation (PMR) physician. A cervical spine (C-spine) radiograph is performed to identify the presence of cervical ribs. A cervical spine magnetic resonance imaging (MRI) scan is performed to evaluate the presence of radiculopathy; if results are abnormal, the patient is evaluated by a spine surgeon. Electromyography (EMG) is performed to rule out ulnar nerve entrapment and carpal tunnel syndrome; if either is present, the patient is evaluated by an extremity surgeon. Physical examination and muscle blocks are performed to determine the predominant site of compression of the brachial plexus at either the scalene triangle or retropectoral space. Vascular ultrasonography performed if elements of venous or arterial thoracic outlet syndrome are present. PT, Physical therapy; Pec Minor, pectoralis minor. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 1318-1323.e1DOI: (10.1016/j.jtcvs.2018.02.096) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 A, Exposure of the right first rib by the supraclavicular approach. Note that a small fraction of the first rib is visible following retraction of the brachial plexus and the subclavian artery. B, Unrivaled exposure of the entire right first rib is provided by a right robotically assisted thoracoscopic approach, requiring no retraction of neurovascular structures. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 1318-1323.e1DOI: (10.1016/j.jtcvs.2018.02.096) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 Possible format of consent form. (Reprinted with permission from McGraw Hill.) The Journal of Thoracic and Cardiovascular Surgery 2018 156, 1318-1323.e1DOI: (10.1016/j.jtcvs.2018.02.096) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Unrivaled exposure of the first rib through a transthoracic approach. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 1318-1323.e1DOI: (10.1016/j.jtcvs.2018.02.096) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Video 1 A video of B.M.B.’s technique of robotically assisted thoracoscopic first rib resection for neurogenic and venous thoracic outlet syndrome (TOS). I.V., Intravenous; SVC, superior vena cava; Phrenic N., phrenic nerve. Video available at: http://www.jtcvsonline.org/article/S0022-5223(18)30778-5/fulltext. The Journal of Thoracic and Cardiovascular Surgery 2018 156, 1318-1323.e1DOI: (10.1016/j.jtcvs.2018.02.096) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions