Roos Procedure for Thoracic Outlet Syndrome

The cervical rib is an extra rib that arises from the seventh cervical vertebra. It is present in approximately 1% of the general population, and it is bilateral in half of these patients. Women are affected more than men. It is clinically significant when it causes neurovascular compression in the thoracic outlet.

This video demonstrates a Roos procedure done for thoracic outlet syndrome (TOS) due to the presence of a left cervical rib in a 22-year-old female patient. She presented with numbness in the left upper limb for one year, and she also reported left upper limb pain on exertion. There were no features of limb ischemia. She had undergone a Roos procedure three years previously to remove a right cervical rib causing TOS. On examination, results of Adson’s test, a costoclavicular test, and a hyperabduction test were positive in the left upper limb. Chest x-ray showed a left cervical rib. A nerve conduction study of the left upper limb revealed a conduction delay.

She underwent the Roos procedure through the left transaxillary approach. The first rib was identified and excised in total. The cervical rib encasing the brachial plexus was identified. It was dissected and found to have multiple roots to the vertebra. Careful dissection of the cervical rib was done, preserving the brachial plexus and subclavian vessels. The cervical rib was removed in pieces. Perfect hemostasis was achieved. A left pleural drain was placed, and the wound was closed in layers. Postoperatively the patient had mild neuropathy, which improved subsequently with physiotherapy.