Complications and clinical benefits of the combined supra- and infraclavicular approach in neurogenic thoracic outlet syndrome

Background: The objective of this study was to analyze whether the combined supra- and infraclavicular approach for neurogenic thoracic outlet syndrome (nTOS) increases postoperative complications and to determine whether its anatomical advantages translate into improved clinical outcomes without increasing morbidity when compared to isolated supraclavicular approaches. Methods: A retrospective study of 69 procedures performed for nTOS between 2015 and 2024 by a single neurosurgeon. Surgical approaches, intraoperative findings, postoperative complications, and clinical outcomes were analyzed. Results were compared between the combined and isolated supraclavicular approaches using Chi-square testing and logistic regression models. Results: The overall complication rate was 18.8% (13/69). Complications occurred in 22.5% of combined procedures (9/40) and 12.0% of isolated supraclavicular procedures (3/25), with no statistically significant difference ( P = 0.545). All complications were transient, most commonly phrenic nerve palsy (7.2%) and superficial wound infection (5.8%). No permanent brachial plexus or vascular injuries occurred. The combined approach provided significantly better exposure of both proximal and distal compression zones, enabling more complete decompression, which was reflected in a higher rate of clinical improvement (82% vs. 69% in isolated approaches). Conclusion: Although the combined approach presents a numerically higher complication rate, the difference is not statistically significant, and all complications were transient. Its superior anatomical exposure and higher rate of clinical improvement support the combined approach as a safe and advantageous surgical option for patients with suspected multilevel nTOS compression.