When in Doubt, Cut It Out?

The cure for a muscle tension that twisting your body in a state of chronic pain and compressing your thoracic outlet is not to cut it out of the body. Its simply to restore the hyper tone of the muscles to normal tone. —James Stoxen

When Conservative Treatment Fails: Is Surgery the Next Step?

Well, we tried everything, so now what?

Surgery for thoracic outlet syndrome?

You tried conservative treatment, physical therapy, and other nonsurgical treatment options, but after three weeks to three months, a few of the 16 different conservative care approaches fail to produce long-term reduction in nerve compression, blood vessel compression, thoracic outlet compression, and long-term reduction in chronic pain, arm pain, neck pain, shoulder pain, and suffering, you are referred to a thoracic outlet syndrome surgeon. You've tried everything, so I guess it's time to do surgery.

What does the medical community recommend as a minimum conservative treatment program before considering thoracic outlet syndrome surgery?

One doctor at Johns Hopkins recommends an eight-week protocol of physical therapy before referring the patient for surgical evaluation of neurogenic thoracic outlet syndrome.

When do doctors and patients consider thoracic outlet syndrome surgery as the next step?

Most people think if their pain gets really bad, there is one treatment option they can get to relieve the compression of the brachial plexus, subclavian artery, or subclavian vein, and that is surgery. "When in doubt, I'll just have the surgeon cut it out."

In their hopes and dreams, they think that the doctor can cut the pain out of the body. That is just a dream. Even though you don't want surgery, you might get to the point where the suffering from chronic pain, arm numbness, hand tingling, muscle weakness, and thoracic outlet compression makes you feel so miserable, for so long, that you'll do anything! You can't think that way!

The 10 Reasons Doctors and Patients Consider Surgery

After reviewing more than 2,300 scientific papers, citations, articles, and books, I've come across these seemingly possible reasons your doctor might recommend thoracic outlet syndrome surgery, first rib resection, scalenectomy, or another surgical decompression procedure as the next step.

1. Paget-Schroetter syndrome (effort thrombosis, venous thoracic outlet syndrome)
2. Subclavian vein thrombosis, venous thrombosis, blood clot, and vascular reconstruction
3. Arterial thoracic outlet syndrome, subclavian artery compression, and arterial compression
4. Limb-threatening vascular complications, critical limb ischemia, or loss of circulation
5. Long-term nerve compression, chronic brachial plexus compression, or long-standing thoracic outlet compression
6. Completed and successful initial treatment of subclavian vein thrombosis followed by consideration of thoracic outlet decompression surgery
7. Neurologic deficit, including muscle weakness, loss of sensation, hand weakness, and decreased sensation
8. Intractable chronic pain, persistent neck pain, shoulder pain, arm pain, and refractory pain
9. Surgery performed for all the wrong reasons, including misdiagnosis, incorrect diagnosis, or failure to identify the true cause of neurovascular compression
10. Failure of a carefully supervised physical therapy program, rehabilitation program, and other conservative treatment approaches before considering surgical intervention

When Conservative Treatment Fails: Is Surgery the Next Step?

Well, we tried everything, so now what?

Surgery for thoracic outlet syndrome?

You tried conservative treatment, physical therapy, rehabilitation, postural correction, and other nonsurgical treatment options, but after three weeks to three months, a few of the 16 different conservative care approaches fail to produce long-term reduction in nerve compression, brachial plexus compression, blood vessel compression, subclavian artery compression, subclavian vein compression, thoracic outlet compression, and long-term reduction in chronic pain, arm pain, neck pain, shoulder pain, upper back pain, arm numbness, hand tingling, and suffering, you are referred to a thoracic outlet syndrome surgeon, vascular surgeon, or peripheral nerve surgeon. You've tried everything, so I guess it's time to do surgery.

What does the medical community recommend as a minimum conservative treatment program, physical therapy program, or rehabilitation protocol before considering thoracic outlet syndrome surgery?

One doctor at Johns Hopkins recommends an eight-week protocol of physical therapy, therapeutic exercise, and rehabilitation before referring the patient for surgical evaluation of neurogenic thoracic outlet syndrome (1).

When do doctors and patients consider thoracic outlet syndrome surgery, thoracic outlet decompression surgery, or first rib resection as the next step?

Most people think if their pain gets really bad, there is one treatment option they can get to relieve the compression of the brachial plexus, subclavian artery, or subclavian vein, and that is surgery. "When in doubt, I'll just have the surgeon cut it out."

In their hopes and dreams, they think that the doctor can cut the pain out of the body. That is just a dream. Even though you don't want surgery, you might get to the point where the suffering from chronic pain, persistent pain, arm numbness, hand tingling, muscle weakness, loss of grip strength, nerve pain, and thoracic outlet compression makes you feel so miserable, for so long, that you'll do anything! You can't think that way!

The 10 Reasons Doctors and Patients Consider Surgery

After reviewing more than 2,300 scientific papers, citations, articles, and books, I've come across these seemingly possible reasons your doctor might recommend thoracic outlet syndrome surgery, thoracic outlet decompression surgery, first rib resection, scalenectomy, brachial plexus decompression, or another surgical decompression procedure as the next step.

• Paget-Schroetter syndrome (effort thrombosis, venous thoracic outlet syndrome, axillary-subclavian vein thrombosis)
• Subclavian vein thrombosis, venous thrombosis, deep vein thrombosis (DVT), blood clot, venous obstruction, and vascular reconstruction
• Arterial thoracic outlet syndrome, subclavian artery compression, arterial compression, arterial insufficiency, and arterial aneurysm
• Limb-threatening vascular complications, critical limb ischemia, arterial occlusion, or loss of circulation
• Long-term nerve compression, chronic brachial plexus compression, peripheral nerve compression, or long-standing thoracic outlet compression
• Completed and successful initial treatment of subclavian vein thrombosis followed by consideration of thoracic outlet decompression surgery, first rib resection, or venous decompression surgery
• Neurologic deficit, including muscle weakness, loss of sensation, hand weakness, decreased sensation, muscle atrophy, and progressive neurologic impairment
• Intractable chronic pain, persistent neck pain, shoulder pain, arm pain, neuropathic pain, and refractory pain
• Surgery performed for all the wrong reasons, including misdiagnosis, incorrect diagnosis, missed diagnosis, or failure to identify the true cause of neurovascular compression, brachial plexus compression, or vascular compression
• Failure of a carefully supervised physical therapy program, rehabilitation program, exercise therapy, manual therapy, postural correction, and other conservative treatment approaches before considering surgical intervention

Remove the Compression without Surgery

There are examples where patients had Paget-Schroetter syndrome, effort thrombosis, or subclavian vein thrombosis (2) that were treated successfully with catheter-directed thrombolysis (6), followed by anticoagulant therapy with no surgery required (11).

Gabrielle Collison is an incredible athlete I consulted with from London, England, who had a subclavian vein blood clot, venous compression, and effort thrombosis, which were successfully treated without surgery. She is now training harder than ever with no recurrence of venous thoracic outlet syndrome, subclavian vein compression, or blood clots years afterward.

Remove the Compression with Surgery

One study reported that patients treated surgically for Paget-Schroetter syndrome, venous thoracic outlet syndrome, and subclavian vein compression had better functional outcomes than those managed conservatively. Prompt catheter-directed thrombolysis, followed by thoracic outlet decompression surgery, was superior to delayed management with respect to rethrombosis, venous patency, and functional outcome. The medical records of patients treated for Paget-Schroetter syndrome over more than 16 years were analyzed. Patients were divided into four groups according to their management (12).

The problem with considering this study is that no one knows what conservative treatment, physical therapy, manual therapy, or nonsurgical treatment was provided. I have found most conservative care delivered in a hospital setting is not very successful because there is no one to adjust the first rib, restore costoclavicular space, reduce subclavian vein compression, or perform the amount of deep tissue therapy required for complete thoracic outlet decompression.

When Surgery May Be Necessary

1. Thrombosis: Post-Subclavian Vein Thrombosis—Vessel Reconstruction

As the compression of the subclavian artery continues, it irritates the arterial wall, causing arterial damage. This scar tissue within the artery can lead to turbulent blood flow, increasing the risk of arterial thrombosis. A blood clot may then detach from the artery wall as an arterial embolus (13), potentially blocking blood flow farther downstream.

2. After Completed and Successful Initial Treatment of Subclavian Vein Thrombosis

Doctors often recommend surgery after subclavian vein thrombosis, effort thrombosis, or Paget-Schroetter syndrome. The goal of surgery is to eliminate the compressive force that caused the subclavian vein to collapse. This compression is commonly produced by scalene muscle spasm, an elevated first rib, abnormal positioning of the clavicle (collarbone), and narrowing of the costoclavicular space, all of which contribute to venous compression.

3. Arterial Compression

Arterial thoracic outlet syndrome, subclavian artery compression, and arterial insufficiency occur in fewer than 5 percent of all patients with thoracic outlet syndrome (7).

Arterial thoracic outlet syndrome is defined as an objective abnormality of the subclavian artery caused by extrinsic compression and subsequent arterial damage from an anomalous first rib, cervical rib, fibrous band, or other abnormal structure located at the base of the scalene triangle (14).

Of course, if there is a clavicle fracture (broken collarbone) that healed improperly and resulted in a subclavian artery aneurysm, or if there is a subclavian vein blood clot that could dislodge as a pulmonary embolus and travel to the lungs causing a pulmonary infarction, then surgery is appropriate. Subclavian artery aneurysms are uncommon but may have devastating consequences, including acute limb ischemia, arterial embolism, or even loss of the affected limb (8).

These severe arterial complications, vascular complications, and limb-threatening ischemic events can also result from delayed treatment. Early recognition, accurate diagnosis, and timely treatment offer the best opportunity to prevent these serious outcomes (7).

4. Limb-Threatening Complications

More advanced scarring of the inside of the subclavian artery, arterial wall, or blood vessel can cause arterial thrombosis, arterial blood clots, or arterial occlusion, resulting in potentially limb-threatening ischemia. Limb-threatening ischemia occurs when the cells in your arm die because they no longer receive enough oxygen-rich blood, arterial blood flow, or circulation. If enough cells die, the arm tissue becomes nonviable tissue, resulting in tissue necrosis or gangrene, and may require limb amputation (13). If your arm is blue, gray, or red, is extremely swollen and cold, you may have an arterial blood clot, vascular obstruction, or acute arterial occlusion that places you at risk of losing a limb to amputation.

5. Long-Term Compression and Chronic Scar Tissue

Some patients end up this way because they were misdiagnosed, while others were underdiagnosed or received an incorrect diagnosis. They might have been diagnosed with carpal tunnel syndrome, undergone carpal tunnel release surgery, and their symptoms did not subside. Then they may have been diagnosed with a cervical herniated disc, bulging disc, or cervical radiculopathy, undergone spine surgery or neck surgery, and still their symptoms did not improve.

Finally, after several years, they are correctly diagnosed with thoracic outlet syndrome. However, by this time, extensive scar tissue, fibrosis, soft tissue adhesions, and connective tissue scarring have developed throughout the area. The muscles, fascia, and ribs become restricted with dense scar tissue, making rib repositioning, first rib mobilization, and compression reduction much more difficult.

Other patients are correctly diagnosed with thoracic outlet syndrome early but seek treatment from 10–15 or more different physical therapists, chiropractors, pain specialists, orthopedic surgeons, neurologists, massage therapists, and other conservative care providers before eventually giving up and choosing surgery.

Some patients simply become exhausted from years of chronic pain, persistent nerve compression, muscle tightness, arm numbness, hand tingling, and functional disability. Eventually, they schedule an appointment with a surgeon hoping that surgery will finally end their suffering.

One study conducted by the Department of Environmental Health at the University of Washington School of Public Health and Community Medicine determined that one of the strongest predictors of failed surgery was the length of time it took physicians to correctly diagnose the patient after the original injury (15).

Many of my patients, like Sonny Burke, experienced long-term nerve compression, chronic compression, long-standing disability, and significant functional loss, yet we were still able to successfully reverse the condition. Learn more about Sonny Burke's case on the thoracic outlet syndrome website at www.thoracicoutletsyndrome.org.

6. Neurologic Deficits, Nerve Compression, and Muscle Weakness

When patients develop neurologic deficits or symptoms such as arm numbness, hand tingling, pins and needles, radiating arm pain, shooting nerve pain, muscle weakness, loss of sensation, or arm heaviness, they often become frightened and immediately seek medical attention. Many first visit their primary care physician or family doctor, who commonly refers them to a neurologist, neurosurgeon, or spine specialist.

Many patients do not realize that when the cause of nerve compression is removed, symptoms such as numbness, tingling, radiating pain, burning pain, and nerve irritation frequently improve. Even when deeper portions of the brachial plexus or peripheral nerves have been compressed, removing the source of compression often allows muscle atrophy, muscle wasting, and loss of strength to recover through active rehabilitation, therapeutic exercise, and progressive strengthening.

Patients with significant neurologic deficits, motor weakness, or sensory loss should strongly consider obtaining a second surgical opinion before proceeding with an operation.

7. Intractable Pain

Some physicians believe it is medically necessary to perform surgery on patients with intractable pain resulting from thoracic outlet syndrome (16).

Research suggests that more than 40 percent of adults experience chronic pain, persistent pain, or recurrent musculoskeletal pain. However, there is an important distinction between chronic pain and intractable pain (18) (17). Individuals with intractable pain experience constant pain, severe pain, unrelenting pain, debilitating pain, and pain that does not respond to conventional treatment.

8. Surgery Performed for All the Wrong Reasons

In a 2011 study published in Surgical Neurology International, physicians from the Department of Neurological Surgery at Albert Einstein College of Medicine evaluated 274 patients presenting with neck pain, back pain, spinal disorders, and other musculoskeletal complaints during a one-year period. Of those 274 consultations, 45 patients had previously been told by outside surgeons that they required surgery, even though their neurological examinations, diagnostic imaging, and radiographic findings were essentially normal (19).

In that same USA Today article mentioned previously, John Santa, a physician and former health system administrator who became director of the Consumer Reports Health Ratings Center in 2008, was quoted, I think there are a very small percent of doctors who are crooked, maybe 1 or 2 percent . . .

I think there's a higher percentage who are not well trained or not competent to determine when surgery is necessary . . . Then you have a big group who are more businessmen than medical professionals—doctors who look at those gray cases and say, "Well, I have enough here to justify surgery, so I'm going to do it." (20)

In a study by Cherington and Cherington, published in the May 1992 edition of Neurology, researchers found that patients without private health insurance or workers' compensation insurance were rarely diagnosed as having thoracic outlet syndrome. The study also reported that Medicaid patients almost never underwent thoracic outlet syndrome surgery. Could it be because Medicaid reimbursement for these surgical procedures is significantly lower? (21)

Cherington and Cherington go further to imply that surgeons, according to the potential reimbursement, make the diagnosis available for that surgical procedure (21).

There is some controversy in the medical studies about thoracic outlet syndrome surgery, surgical decompression, and first rib resection. For example, as previously mentioned, Campbell and Landau estimated that surgeons diagnose thoracic outlet syndrome 100 times more frequently than the neurologists who don't perform thoracic outlet decompression surgery (22).

What I recommend is to go to a surgeon and tell them you have no insurance and see what the diagnosis and recommended treatment plan, conservative treatment, or surgical treatment approach is. That way you will see what is REALLY medically necessary!

According to a USA Today review of government records and medical databases, tens of thousands of patients undergo unnecessary surgery, elective surgery, and unnecessary surgical procedures every year! In fact, unnecessary surgeries might account for 10–20 percent of all operations in some specialties, according to a review of in-depth studies and data generated by both government and academic sources (20).

Failure of Conservative Treatment and Physical Therapy

1. Failure of a Carefully Supervised Physical Therapy Program

In Chapter 10, "What Treatment Doesn't Work and Why?" you learned the logical reasons why the 16 different conservative treatment approaches, physical therapy treatments, rehabilitation programs, and nonsurgical treatment options by themselves cannot reverse thoracic outlet syndrome. Instead of going over them again, I am going to explain in Chapter 13, "What Works and Why?" the difference between a poorly designed and supervised physical therapy program, rehabilitation program, and my Human Spring Approach.

Everyone agrees . . . compression of the brachial plexus, subclavian artery, or subclavian vein is the cause of thoracic outlet syndrome.

When doctors say surgery is recommended for thoracic outlet syndrome, they believe they have done everything medically possible to remove the cause of the neurovascular compression, brachial plexus compression, arterial compression, or venous compression within the thoracic outlet, but they failed. You tried everything! You have been in so much agony, for so long, and nothing is working, so maybe the doctor can do surgery and cut out the cause of your pain and finally you will be pain free. Doctors call it surgical decompression or thoracic outlet decompression surgery.

What Is Surgical Decompression?

What is involved in surgical decompression for thoracic outlet syndrome?

It is neck surgery, shoulder surgery, and chest surgery involving the surgical removal of muscles and sometimes ribs that are believed to be causing nerve compression and blood vessel compression within the thoracic outlet. What muscles and ribs are surgically removed from the area of compression of your thoracic outlet and tunnel?

• The main surgery for thoracic outlet syndrome involves the surgical removal (resection) of the anterior scalene muscle, the middle scalene muscle, and the first rib, because doctors believe they are responsible for compression within the interscalene triangle and the costoclavicular space.
• The less common surgery for thoracic outlet syndrome involves the surgical removal (resection) of the pectoralis minor muscle, because doctors believe it is responsible for compression beneath the pectoralis minor space and the costoclavicular space.
• Some surgeons feel the best strategy involves the surgical removal of the anterior scalene muscle, the middle scalene muscle, the pectoralis minor muscle, and the first rib to achieve the greatest amount of thoracic outlet decompression.

Common Surgical Procedures

What are the different surgical procedures used for thoracic outlet syndrome?

There are several thoracic outlet decompression procedures used to relieve brachial plexus compression and vascular compression. The two most common are the transaxillary first rib resection and the supraclavicular scalenectomy. Another commonly performed procedure is the pectoralis minor tenotomy.

• Supraclavicular scalenectomy
• Transaxillary first rib resection
• Combined supraclavicular and transaxillary approach
• Endoscopic-assisted transaxillary first rib resection
• Pectoralis minor tenotomy

Supraclavicular Surgical Approach

The entry for the supraclavicular surgical approach is at the top of the shoulder, where it produces a visible surgical scar (26). The supraclavicular approach provides surgeons with an excellent view of the subclavian artery, brachial plexus, and surrounding neurovascular structures.

The primary goal of thoracic outlet decompression surgery is to remove whatever is compressing the neurovascular bundle, including the brachial plexus, subclavian artery, and subclavian vein. What doctors have concluded is that the primary structures responsible for this compression are the following:

• The Anterior Scalene Muscle
• The Middle Scalene Muscle
• The First Rib
• Any Cervical Ribs

Resection of the First Rib

There is disagreement in the thoracic outlet surgery, vascular surgery, and peripheral nerve surgery community whether it is medically necessary to remove your entire first rib or only a portion of it. Most surgeons have found that an incomplete first rib resection might lead to a recurrence of thoracic outlet syndrome symptoms, arm numbness, hand tingling, shoulder pain, and nerve compression after surgery. That is because scar tissue, fibrosis, and calcium deposits can grow on the stump of the severed rib and cause irritation in the area or recompression of the brachial plexus, subclavian artery, or subclavian vein (15).

If the first rib floor is lifted into the thoracic outlet by the anterior scalene muscle and middle scalene muscle, and you surgically remove that, what if the shoulder girdle, clavicle, and scapula are still being pulled downward by tight muscles into the thoracic outlet causing brachial plexus compression and vascular compression? In that case, you may still have persistent symptoms after first rib resection surgery.

Supraclavicular Surgical Approach

Incision – A 5 to 7 cm long supraclavicular incision is made 1 to 2 cm above the collarbone (clavicle). The pad of fat over the area is moved aside to expose the thoracic outlet anatomy.

Identification and Protection of Important Nerves and Blood Vessels

The surgeon identifies and carefully protects the accessory phrenic nerve, phrenic nerve, long thoracic nerve, small sensory nerve branches, and anterior jugular veins. The suprascapular artery and transverse cervical artery are also identified and preserved. Special care must be taken not to stretch, compress, or accidentally cut the phrenic nerve, because it supplies the diaphragm, the primary muscle responsible for breathing. Injury to the phrenic nerve can result in diaphragm paralysis, reduced lung capacity, shortness of breath, and impaired respiratory function.

Resection of the Anterior Scalene Muscle

The anterior scalene muscle forms part of a muscular sling together with the middle scalene muscle. The anterior scalene is detached from its insertion on the first rib and then released as high into the neck as possible to reduce brachial plexus compression and subclavian artery compression.

Resection of the Middle Scalene Muscle

The middle scalene muscle is then detached from the first rib. During this step, the surgeon must carefully protect the dorsal scapular nerve and the long thoracic nerve, both of which travel through or adjacent to the middle scalene muscle and may be vulnerable to injury.

Resection of the First Rib

Using Kerrison punches (Kerrison rongeurs), the surgeon cuts through the first rib where it attaches to the thoracic spine. A Kerrison rongeur removes small pieces of bone with each bite, allowing the rib to be cut gradually and safely. Because only a small amount of bone is removed with each bite, it may require five to six bites to completely divide the first rib.

When in Doubt, Cut It Out?

Resection of the Subclavius Muscle

The surgeon cuts through the subclavius muscle, which attaches to the first rib beneath the clavicle. After releasing the subclavius muscle, the first rib is divided at its attachment near the sternum.

Resection of the Intercostal Muscles

After the first rib has been divided from both the sternum and the thoracic spine, the surgeon cuts the intercostal muscles located between the first rib and second rib. These muscles help stabilize the rib cage during breathing.

Once the first rib has been completely released from its superior, inferior, anterior, and posterior attachments, it is removed intact. The surgeon then inspects the brachial plexus, subclavian artery, and subclavian vein to ensure adequate decompression before closing the incision and transferring the patient to the recovery room.

The Transaxillary Surgical Approach

Surgical Set Up – The patient's arm is held in the position noted in the illustration primarily by attaching it to a rack that anchors it in a position to expose the axilla (armpit) for thoracic outlet decompression surgery. This can cause significant strain on the shoulder joint, upper extremity, and even the brachial plexus nerves. This is why it is recommended that the surgical attendant return the arm to the neutral position periodically during the course of the operation to reduce the risk of nerve injury, shoulder injury, elbow injury, or brachial plexus damage.

Incision – The incision is made in the axilla (armpit) below the hairline. The cut extends from the pectoralis major muscle (chest muscle) to the latissimus dorsi muscle (back muscle).

When the surgeon reaches the chest wall, the first rib is identified along with important neurovascular structures that must be protected, including the intercostobrachial nerve, long thoracic nerve, subclavian artery, subclavian vein, and the brachial plexus.

Anterior Scalene Muscle Resection – The surgeon uses Metzenbaum scissors to divide the anterior scalene muscle from its attachment to the first rib. The phrenic nerve, which controls the diaphragm and normal breathing, runs across the surface of the anterior scalene muscle, so extreme care must be taken to avoid phrenic nerve injury, which can result in diaphragm paralysis and breathing difficulties.

Middle Scalene Muscle Resection – The middle scalene muscle is divided from its attachment on the first rib using Metzenbaum scissors. During this portion of the procedure, the surgeon must avoid injuring the long thoracic nerve, which passes directly through the middle scalene muscle. Damage to this nerve can paralyze the serratus anterior muscle, resulting in a complication known as winged scapula or scapular winging.

First Rib Resection – The first rib is separated from its attachments to the subclavius muscle, costochondral junction, and sternum (breastbone). After the first rib is released, the remaining portions are removed using a Kerrison rongeur or other bone-cutting instruments designed for first rib resection.

Intercostal Muscle Resection – After the first rib has been separated from the sternum, spine, and surrounding attachments, the surgeon divides the intercostal muscles located between the first rib and second rib. Once the first rib is completely freed from its superior, inferior, anterior, and posterior attachments, it is removed intact. The incision is then closed, and the patient is transferred to the postoperative recovery room.

Transaxillary Surgical Approach

The transaxillary surgical approach begins with an incision in the armpit (axilla). The surgeon identifies the anterior scalene muscle and middle scalene muscle, which are surgically removed to relieve nerve compression and blood vessel compression within the thoracic outlet. One advantage of this technique is that it produces less visible scarring because the incision is hidden within the axillary fold.

The transaxillary approach does not allow adequate access for vascular reconstruction, arterial repair, or venous repair in patients with subclavian artery pseudoaneurysm (23), subclavian artery aneurysm, or other forms of vascular thoracic outlet syndrome requiring reconstruction. Although subclavian artery aneurysms are uncommon, they may lead to serious complications, including arterial thrombosis, distal embolization, limb ischemia, and possible loss of the upper extremity (24). Patients requiring arterial reconstruction, vascular bypass, or subclavian artery repair generally require resection of the artery through a supraclavicular surgical approach (25) rather than a transaxillary approach.

Pectoralis Minor Tenotomy

The pectoralis minor tenotomy is a surgical procedure performed to surgically remove the pectoralis minor muscle. This is because the pectoralis minor may be putting pressure on the brachial plexus, subclavian artery, and subclavian vein directly, dragging the shoulder down into the thoracic outlet and costoclavicular space, or both.

How do doctors determine whether they are going to surgically resect the pectoralis minor muscle, the anterior scalene muscle, the middle scalene muscle, and first rib, or all of the above?

In one study, the choice of operation was determined by responses to diagnostic muscle blocks (local anesthetic injections). Patients first had their pectoralis minor muscle injected. If that relieved the majority of the symptoms of brachial plexus compression, vascular compression, and thoracic outlet compression, then the doctor would perform the pectoralis minor resection. If the injection did not improve symptoms, then the doctor would inject the anterior scalene and middle scalene muscles to determine whether that would reduce the symptoms. If the scalene muscle injection caused the nerve compression symptoms, arm pain, arm numbness, hand tingling, and outlet compression symptoms to subside, the doctor would surgically remove the scalene muscles and the first rib (27).

Some doctors surgically remove all three muscles and the first rib, believing it provides a better statistical outcome. If they do not make the correct differential diagnosis, they may try to avoid performing a second thoracic outlet decompression surgery. Another way of putting it is, "When in doubt, cut them all out."

In another study, patients who had only the pectoralis minor resection (pectoralis minor tenotomy) had better outcomes than those who underwent a combination of pectoralis minor resection, scalenectomy, and first rib resection. They determined that the success rates with a one- to three-year follow-up for the pectoralis minor (PM)-alone group were 90 percent good–excellent, 2 percent fair, and 8 percent failed; for the combined surgery group, success rates were 35 percent good–excellent, 19 percent fair, and 46 percent failed (27).

Pectoralis Minor Tenotomy Surgical Procedure

The incision is made in the axilla (armpit) using a 4–7 cm surgical incision placed 1–2 cm above the hairline, in the same location used for the transaxillary first rib resection approach.

The pectoralis major muscle is retracted, and the pectoralis minor muscle is identified by its attachment to the coracoid process of the scapula and the third, fourth, and fifth ribs.

The surgeon divides the pectoralis minor tendon at its attachment to the coracoid process.

The lateral pectoral nerve passes through the pectoralis minor muscle. The surgeon must avoid injuring these motor nerves, because they innervate the pectoralis major muscle. If these nerves are damaged, the pectoralis major may become weak and eventually atrophy, resulting in loss of chest muscle strength and shoulder dysfunction.

Surgical Removal of Cervical Ribs

Cervical ribs are twice as common in women as men (68 percent versus 32 percent, respectively), occur on both sides in more than 50 percent of cases, and are asymptomatic (nonpainful) in approximately 90 percent of individuals (29).

If you are an adult who recently developed neck pain, shoulder pain, arm numbness, hand tingling, or other symptoms of neurogenic thoracic outlet syndrome, and your doctor tells you that a cervical rib seen on an X-ray is the cause of your symptoms, remember this important fact: you have had that cervical rib your entire life, yet it never caused symptoms before. Simply finding a cervical rib on an X-ray does not prove it is the source of your nerve compression, vascular compression, or chronic pain. The true cause should be confirmed with a thorough differential diagnosis, physical examination, and evaluation of the biomechanics contributing to thoracic outlet compression.

Cervical Ribs in Children

Based on one doctor's experience, symptomatic cervical ribs, congenital cervical ribs, and thoracic outlet compression should not be considered pathology peculiar to the adult population. Although uncommon, children might present with symptomatic cervical ribs, neurovascular compression, or brachial plexus compression that necessitate surgical intervention (30).

I would not recommend the surgical removal of your child's cervical ribs, first rib, or the removal of any ribs unless you have exhausted the protocols for the Human Spring Approach, conservative treatment, non-surgical treatment, and compression reduction techniques I have listed in Chapter 13. Please call me if the doctor is recommending surgery for your child.

One study stated that all arterial thoracic outlet syndrome, arterial compression, and subclavian artery compression cases are the result of cervical ribs in their experience and in those of other investigators (31).

What Kind of Cervical Ribs Respond to Surgery?

This same study mentioned above claimed patients with complete cervical ribs had better surgical outcomes than did those with incomplete cervical ribs. Of 12 operations for complete cervical ribs, only one failure (9 percent) was seen, with two fair results (16 percent), and nine good or excellent results (75 percent) (31).

Cervical Rib Resection After Auto Accidents and Work Injuries

One study that surveyed patients eight years after the surgical removal of cervical ribs, cervical rib resection, and thoracic outlet decompression surgery found that 43 percent of the patients who had their cervical ribs resected were asymptomatic. In 57 percent of the patients, the surgery did not bring about relief of symptoms (32), including neck pain, shoulder pain, arm pain, numbness, and tingling.

One study, titled "Management of Cervical Ribs and Anomalous First Ribs Causing Neurogenic Thoracic Outlet Syndrome," published the results of 65 operations performed for abnormal cervical ribs, anomalous first ribs, and bony abnormalities that produced symptoms of neurogenic thoracic outlet syndrome, brachial plexus compression, and nerve compression (33).

The conservative therapy consisted of physical therapy, including neck stretching exercises, scalene muscle stretching, pectoralis minor stretching, abdominal breathing exercises, posture correction, postural rehabilitation, nerve gliding exercises, and, after 1998, the Feldenkrais Method. None of these therapies reduced the muscle spasms, muscle tension, and compression of the thoracic outlet that compress the brachial plexus, subclavian artery, and subclavian vein, so these patients had no chance of improving.

The indications for surgery were disabling neck pain, shoulder pain, arm pain, paresthesia, hand numbness, hand tingling, and failure to respond to conservative treatment, physical therapy, and non-surgical management.

• The failure rate for patients in whom symptoms developed after work-related injuries, occupational injuries, or repetitive stress injuries at work was 42 percent.
• The failure rates for patients whose symptoms followed an auto accident, whiplash injury, or developed spontaneously were 26 percent and 18 percent, respectively.
• The failure rate for cervical rib resection without first rib resection in the work-related injury group was 75 percent, compared with a failure rate of 38 percent in the non-work-related injury group.

Cervical Rib and First Rib Resection Failure

In contrast, when both cervical and first ribs were resected, the failure rate in the work-related group fell to 25 percent and in the non-work-related group to 20 percent (33). There's that concept of "when in doubt, cut it all out," again.

The cervical ribs were not the problem. The problem was obviously that the cervical ribs and first ribs elevated up into the thoracic outlet, causing compression of the brachial plexus, subclavian artery, and subclavian vein during the accident. Apparently, the conservative treatment, physical therapy, and non-surgical treatment were not effective in reducing the muscle tension that was causing an elevation of the first rib.

When the transaxillary first rib resection and cervical rib resection failed to end their suffering, seven of them were talked into another surgery (33).

They had another surgery to surgically remove the anterior scalene muscle, middle scalene muscle, and posterior rib stumps in seven patients. The rest underwent transaxillary first rib resections. Five of the eight operations (63 percent) failed to end their suffering after two surgeries (33).

Why Do Cervical Rib and First Rib Resections Fail?

One study reported on the reasons why cervical rib surgery, first rib resection, and thoracic outlet decompression surgery fail. One study reported all the reasons why 182 patients' rib resections failed (29).

Of the 182 patients, 154 had a substantial piece of rib remaining from the initial procedure. Also, these were some of the technical errors made by doctors in the initial operation:

• The surgeon resected the second rib instead of the first rib.
• The surgeon resected the first rib and forgot, or chose, to leave the cervical rib in place (29).
• The surgeon resected the cervical rib and did not resect an abnormal first rib (34) (29).

Which Surgical Approach Produces the Best Results?

There was a study done in 1989 which compared the results of the transaxillary first rib resection approach with the supraclavicular first rib resection approach. Both methods of thoracic outlet decompression surgery produced similar results, with the transaxillary first rib resection edging out the supraclavicular first rib resection by about three percent (35). If you don't want a scar on your neck, it is better to undergo the transaxillary surgical approach.

I don't perform surgery; however, this is what I found regarding operative time for the different forms of thoracic outlet decompression surgery.

Arterial thoracic outlet syndrome required the longest operating time, averaging 223.5 minutes (approximately four hours), compared with an average of 127 minutes for venous thoracic outlet syndrome and 119 minutes for neurogenic thoracic outlet syndrome, respectively (36).

According to my resources, this is what we found regarding hospital length of stay following surgery.

Patients with arterial thoracic outlet syndrome required the longest in-hospital stay of up to six days. Patients with venous thoracic outlet syndrome required approximately five days in the hospital, while patients with neurogenic thoracic outlet syndrome required an average hospital stay of only two days (36).

The hospital costs, surgical costs, and healthcare expenses are not inexpensive if you must pay them yourself.

In a 2007 retrospective analysis of five years (1999–2003) of the Nationwide Inpatient Sample database, it was determined that the mean total hospital charge was $16,160, in inflation-adjusted 2005 dollars. Patients who had vascular thoracic outlet syndrome required significantly longer lengths of stay (7.7 versus 2.4 days) and substantially higher total hospital charges of $53,373 versus $16,160 (37).

Potential Complications of Thoracic Outlet Decompression Surgery

There are several surgical complications, postoperative complications, and vascular and nerve complications associated with thoracic outlet decompression surgery.

In his article entitled Comprehensive Management of Subclavian Vein Effort Thrombosis, there are 16 possible complications of surgery mentioned for thoracic outlet syndrome (10).

The potential complications of surgery are…

• Pneumothorax (Collapsed Lung, Lung Collapse, Air Leak Around the Lung)
• Pleural Effusion (Fluid Around the Lung, Pleural Fluid Accumulation)
• Postoperative Thoracic Duct Lymph Leak (Chyle Leak, Lymphatic Leak)
• Temporary or Permanent Brachial Plexus Injury (Nerve Injury, Arm Weakness, Arm Numbness, Hand Tingling)
• Phrenic Nerve Injury (Diaphragm Paralysis, Breathing Difficulty, Shortness of Breath)
• Long Thoracic Nerve Injury or Dysfunction (Serratus Anterior Weakness, Winged Scapula, Shoulder Blade Instability)
• Subclavian Artery Injury (Arterial Injury, Vascular Injury, Arterial Bleeding, Reduced Blood Flow)
• Subclavian Vein Injury (Venous Injury, Vascular Injury, Venous Bleeding, Venous Compression)
• Postoperative Bleeding (Surgical Bleeding, Hemorrhage, Postoperative Hemorrhage)
• Wound Hematoma (Postoperative Hematoma, Surgical Site Hematoma, Excessive Anticoagulation)
• Residual Subclavian Vein Obstruction (Persistent Venous Compression, Residual Venous Narrowing, Venous Outflow Obstruction)
• Early Postoperative Rethrombosis (Recurrent Blood Clot, Recurrent Deep Vein Thrombosis, Early Venous Thrombosis)
• Late Postoperative Axillary Vein Obstruction (Axillary Vein Narrowing, Chronic Venous Obstruction, Venous Outflow Obstruction)
• Late Postoperative Subclavian Vein Obstruction (Subclavian Vein Narrowing, Chronic Venous Compression, Venous Outflow Obstruction)
• Rethrombosis (Recurrent Blood Clot, Recurrent Venous Thrombosis, Deep Vein Thrombosis Recurrence)
• Recurrent Symptoms (Persistent Pain, Chronic Neck Pain, Shoulder Pain, Arm Pain, Arm Numbness, Hand Tingling, Muscle Weakness, Arm Swelling, Functional Limitations)

1. Pneumothorax (Collapsed Lung)

A pneumothorax (collapsed lung) occurs when air enters the pleural cavity, causing the lung to partially or completely collapse. Common symptoms include sudden chest pain, shortness of breath, difficulty breathing, rapid breathing, dry cough, rapid heart rate, and fatigue.

Because the first rib, pleura, and apex of the lung are located so close together, when the first rib is resected or surgically removed during thoracic outlet decompression surgery, a pneumothorax may occur. One author reported that more than 33 percent of patients experienced a postoperative pneumothorax following surgery (38).

2. Pleural Effusion (Fluid on the Lungs)

Patients may develop pleural effusion as a complication of thoracic outlet decompression surgery (10). Pleural effusion, sometimes called water on the lungs, occurs when excess fluid accumulates between the layers of the pleural membrane surrounding the lungs.

Common symptoms include chest pain, dry cough, shortness of breath, difficulty breathing, and the inability to breathe comfortably unless sitting upright or standing, a condition known as orthopnea.

3. Postoperative Thoracic Duct Lymph Leak

The thoracic duct, the body's largest lymphatic vessel, drains chyle, lymphatic fluid, dietary fats, immune cells, and interstitial fluid from most of the body. It is a very thin-walled, colorless lymphatic channel located close to the thoracic outlet, subclavian vein, internal jugular vein, and brachiocephalic vein; therefore, it is particularly susceptible to surgical injury, thoracic duct trauma, and postoperative lymphatic leak during surgery.

In adults, the thoracic duct transports up to 4 liters of lymph per day. A large portion of the body's lymphatic drainage is collected by this duct before entering the venous circulation. It empties into the bloodstream in the thoracic outlet region near the brachiocephalic vein, at the junction of the internal jugular vein and the left subclavian vein.

Lymph drains into the subclavian vein, while one-way lymphatic valves prevent blood from flowing backward into the thoracic duct, maintaining normal lymphatic circulation.

A cervical chyle leak can spread from the root of the neck into the mediastinum. With sufficient hydrostatic pressure, the accumulation of chyle may rupture into the pleural cavity, forming a chylothorax, which commonly presents with shortness of breath, tachypnea, difficulty breathing, pleuritic chest pain, and respiratory distress.

When the thoracic duct is blocked, torn, or damaged, a large amount of lymphatic fluid can rapidly accumulate in the pleural cavity surrounding the lung. This condition is known as a chylothorax. Although uncommon, it is a serious postoperative complication that may require urgent treatment.

A chyle leak can result in delayed wound healing, dehydration, malnutrition, protein loss, electrolyte imbalance, immune suppression, lymphatic dysfunction, and prolonged hospitalization. Prompt recognition, accurate diagnosis, and early treatment of a thoracic duct injury are essential for optimal surgical recovery and patient outcomes.

4. Brachial Plexus Injury (.6%) (37)

The brachial plexus is a complex network of peripheral nerves that carries motor and sensory nerve signals from the cervical spinal cord to the shoulder, arm, forearm, and hand. A brachial plexus injury occurs when these nerves are stretched, compressed, entrapped, tractioned, or accidentally cut during surgery. Severe brachial plexus nerve injuries can result in arm paralysis, loss of sensation, muscle weakness, and permanent disability.

Signs and symptoms may be mild to moderate and include an electric shock sensation, burning pain, arm numbness, hand tingling, muscle weakness, reduced grip strength, and loss of coordination.

In more severe cases, brachial plexus trauma can produce profound muscle weakness involving the shoulder, arm, and hand, progressing to a complete inability to move the affected arm with complete numbness, loss of motor function, severe nerve pain, or a combination of these symptoms.

There is a recognized risk of brachial plexus injury resulting from excessive nerve retraction, prolonged traction injury, or compression of the nerve trunks with metallic retractors or elastic tape (42). Transaxillary first rib resection carries a significant risk of serious complications, with brachial plexus injury being one of the most common nerve complications.

Even if the injury appears minor, prompt neurological evaluation, nerve testing, and medical treatment may be necessary. Despite surgical repair, some patients experience permanent nerve damage, chronic neuropathic pain, persistent muscle weakness, muscle atrophy, or permanent arm paralysis.

5. Phrenic Nerve Injury

The phrenic nerve supplies the diaphragm, the principal muscle of respiration. The diaphragm is responsible for most of the work of normal breathing, making the phrenic nerve essential for healthy lung function, ventilation, and respiration.

Phrenic nerve injury can result in diaphragm paralysis and has been reported following both the transaxillary and supraclavicular surgical approaches. Diaphragmatic paralysis can significantly reduce lung capacity, resulting in shortness of breath, difficulty breathing, reduced exercise tolerance, and respiratory dysfunction.

During normal breathing, the diaphragm performs most of the work with assistance from the scalene muscles, intercostal muscles, sternocleidomastoid muscles, and trapezius muscles, collectively known as the accessory muscles of respiration. If both diaphragms become paralyzed, these accessory breathing muscles must perform nearly all the work of breathing, often leading to excessive muscular effort and rapid fatigue.

What is even more concerning is that the anterior scalene muscle and middle scalene muscle may already have been surgically removed during thoracic outlet decompression surgery. Loss of diaphragm function, combined with loss of the scalene muscles, can severely compromise breathing mechanics, making every breath more difficult and increasing fatigue, shortness of breath, exercise intolerance, and the risk of respiratory complications.

6. Long Thoracic Nerve Injury/Dysfunction, Long

Thoracic Nerve Palsy (Winging Scapula)

Long thoracic nerve palsy, also known as long thoracic nerve injury or winged scapula syndrome, is a shoulder condition characterized by shoulder pain, shoulder weakness, loss of shoulder movement, and scapular winging due to damage or injury of the long thoracic nerve.

This nerve is formed by the C5, C6, and C7 cervical nerve roots. The roots from C5 and C6 pierce through the middle scalene muscle, while the C7 nerve root passes in front of the middle scalene muscle and behind the anterior scalene muscle.

The long thoracic nerve, which controls the serratus anterior muscle, lies very close to the first rib, upper ribs, and collarbone (clavicle) within the thoracic outlet region. The serratus anterior muscle stabilizes the shoulder blade (scapula) by pulling it forward around the thoracic cage, allowing normal shoulder movement, arm elevation, and overhead function.

Injury to the long thoracic nerve resulting in paralysis or weakness of the serratus anterior muscle can be severely disabling. Patients with long thoracic nerve palsy commonly present with shoulder pain, muscle weakness, limited shoulder elevation, difficulty lifting the arm overhead, scapular instability, and scapular winging.

Because of its long, relatively superficial course close to the skin, the long thoracic nerve is susceptible to direct trauma, traction injury, stretch injury, sports injuries, and surgical injury. It can also be inadvertently damaged or cut during surgery (39) (38) (10).

Long thoracic nerve injuries may also result from carrying heavy backpacks, heavy shoulder bags, or other heavy loads over the shoulder for prolonged periods, producing excessive traction on the nerve.

The C5 and C6 nerve roots pass directly through the middle scalene muscle, one of the muscles commonly removed during thoracic outlet surgery. If the surgeon inadvertently places excessive traction on the nerve or accidentally cuts the long thoracic nerve, it can result in permanent nerve damage, permanent paralysis of the serratus anterior muscle, and a lifelong winging of the shoulder blade (39–41) (scapular winging).

7. Subclavian Artery Injury 1–2% (37)

Subclavian Artery Injury During Surgery

The subclavian artery can be accidentally injured during thoracic outlet surgery because it lies immediately adjacent to the brachial plexus, first rib, and scalene muscles. Injury to this major blood vessel may require immediate vascular repair, vascular surgery, or arterial reconstruction, resulting in significantly longer hospital stays, increased surgical complications, greater healthcare costs, and an increased risk of bleeding complications.

8. Subclavian Vein Injury 1–2% (37)

Subclavian Vein Injury and Major Bleeding Complications

Injury to the subclavian vein or subclavian artery can occur during surgery because surgeons must manipulate the blood vessels, brachial plexus nerves, and surrounding tissues with surgical instruments in this confined anatomical space. These delicate arteries, veins, and nerves are frequently retracted with metal surgical instruments, placing them under significant traction and increasing the risk of vascular injury.

Damage to the subclavian vein or subclavian artery may result in massive hemorrhage, life-threatening bleeding, or the need for emergency vascular repair. If a surgical team is not fully prepared to recognize and control major vascular bleeding, they should not be performing this type of surgery (38).

9. Postoperative Bleeding

Postoperative Hemorrhage (Post-Surgical Bleeding): Bleeding after a thoracic outlet decompression surgery, first rib resection, scalenectomy, or other thoracic outlet surgical procedure. After surgery, it is common to have some minor bleeding. Sometimes patients bleed excessively due to an injury to a blood vessel, subclavian artery, or subclavian vein.

One of the main symptoms of postoperative bleeding is increased pain, but if there is enough blood loss, the patient may complain of weakness, lightheadedness, shortness of breath, rapid heart rate, dizziness, and other symptoms of hemorrhagic shock, low blood pressure (hypotension), and decreased blood circulation. If you have these signs or symptoms, call 911 and your surgeon immediately.

10. Hemorrhage or Bleeding

After thoracic outlet surgery, there can be postoperative bleeding or postoperative hemorrhage (10). Injury to the subclavian vein, subclavian artery, or surrounding major blood vessels can occur during surgery because there is extensive manipulation of the brachial plexus, arteries, and veins within the thoracic outlet. During surgery, surgeons often retract these delicate nerves and blood vessels using metal surgical instruments, placing them under significant traction or stretch. This creates the potential for massive hemorrhage, vascular injury, and life-threatening blood loss. If surgeons are not prepared to manage major vascular bleeding, they should not be performing this operation (38).

11. Wound Hematoma (Associated With Excessive Anticoagulation)

A wound hematoma is similar to a bruise. It is a localized collection of blood outside the blood vessels that develops after surgery due to postoperative bleeding. Some medications, including aspirin, anticoagulants (blood thinners), and low-dose heparin, may increase the risk of excessive bleeding after surgery. Patients receiving aspirin or low-dose heparin have a slightly higher risk of developing this postoperative complication.

See your doctor if your symptoms do not improve after two weeks. Depending on the size, location, and cause of the hematoma, the area may need to be surgically drained, monitored with follow-up examinations, or allowed to gradually resolve on its own.

12. Residual Subclavian Vein Obstruction

Residual subclavian vein obstruction is a postoperative complication in which the subclavian vein remains partially compressed or obstructed after surgery. This means the operation did not completely relieve the venous compression, resulting in continued restriction of venous blood flow, persistent swelling, pain, or other vascular symptoms.

13. Early Postoperative Rethrombosis

The goal of thoracic outlet decompression surgery is to restore normal blood flow through a compressed subclavian artery or subclavian vein. Early postoperative rethrombosis occurs when a new blood clot (thrombus) forms, causing partial or complete blockage of the artery or vein shortly after blood flow has been restored following surgery.

14. Late Postoperative Axillary Vein Obstruction

Late postoperative axillary vein obstruction occurs when the axillary vein becomes narrowed or obstructed after thoracic outlet decompression surgery, resulting in reduced venous blood flow, arm swelling, pain, heaviness, or other symptoms of venous thoracic outlet compression.

15. Late Postoperative Subclavian Vein Obstruction

Late postoperative subclavian vein obstruction occurs when the subclavian vein becomes narrowed or obstructed after thoracic outlet decompression surgery, reducing venous circulation and causing persistent swelling, discomfort, arm fatigue, or recurrent vascular compression symptoms.

16. Rethrombosis

Rethrombosis occurs when an artery or vein becomes partially or completely occluded by a new blood clot (thrombus) after surgery has successfully restored blood flow. This postoperative complication may occur shortly after surgery and can compromise the success of the procedure by reducing normal arterial or venous circulation.

17. Recurrent Symptoms

Recurrent symptoms mean you continue to experience the same major symptoms after surgery, or your symptoms become worse instead of improving. Persistent neck pain, shoulder pain, arm pain, arm numbness, hand tingling, arm weakness, vascular symptoms, or other nerve compression symptoms after surgery are often caused by one or more of the following:

• Incomplete first rib resection or incomplete decompression
• Persistent deep tissue compression
• Reattached scalene muscles (recurrent scalene muscle compression)
• Postoperative scar tissue (fibrosis or adhesions)
• Bony regeneration or regrowth of bone

Surgery for Persistent or Recurrent Symptoms

If patient symptoms are severe, they might have thoracic outlet decompression surgery, thinking that surgery is going to fix it. However, one author stated that recurring symptoms develop in 15–20 percent of patients (43). That author has also stated the return of symptoms after thoracic outlet surgery is more than 40 percent (33), and one author stated it was as high as 61.2 percent (44).

Scar tissue can build up at the surgical site, leading to brachial plexus entrapment, nerve entrapment, and recurrent compression of the neurovascular bundle because of these adhesions. This will all depend on your after-surgery rehabilitation program, however, even with the best post-operative rehabilitation and physical therapy, some patients develop a large amount of scar tissue in the surgical area. Although surgery removes tissues that may contribute to compression, scar tissue formation, post-surgical adhesions, and fibrosis can create new areas of compression affecting the nerves and blood vessels.

They only surgically removed three muscles when you now know that there are 10 muscles capable of compressing the thoracic outlet, contributing to brachial plexus compression, subclavian artery compression, and subclavian vein compression.

Choosing a Thoracic Outlet Surgeon

Who is the best surgeon for thoracic outlet syndrome surgery, thoracic outlet decompression surgery, or first rib resection surgery?

This should be determined by long-term surgical outcomes, success rates, complication rates, and patient satisfaction. If you are considering surgery, some say it is better to go to a teaching hospital, academic medical center, or high-volume thoracic outlet surgery center.

A patient recently contacted me after his thoracic outlet syndrome symptoms, including arm numbness, hand tingling, and neck pain, returned following surgery. Before he made his trip to Chicago for treatment, I asked him to send me a copy of his surgeon's operative report. On the bottom it read, "As the attending physician, I was present and scrubbed throughout the entire procedure." He later found out that the attending physician he chose did not perform most of the surgery. Residents, under the attending physician's guidance and supervision, performed much of the procedure.

When you have surgery at a teaching hospital with a surgical residency program, surgical residents are commonly involved with your operation. While attending surgeons are required to supervise the procedure, residents learn by performing portions of surgery under direct supervision—that is how the medical education system works.

All residents are closely supervised at each step of the procedure and are permitted to perform progressively more of the operation as they demonstrate competency in each surgical skill. By the time they complete their surgical residency, which typically lasts five to ten years depending on the specialty, they are capable of performing an entire operation without direct supervision from an attending physician.

Questions to Ask Before Neck or Thoracic Outlet Surgery

All patients should be well informed before making major health care decisions such as neck surgery, thoracic outlet surgery, or first rib resection surgery. If your surgeon has not discussed these issues with you, be proactive and ask questions such as:

• Who will be performing my surgery?
• Which parts of the surgery will a resident be allowed to perform?
• How much experience do they have performing this specific procedure?
• Which parts of the surgery will you personally perform?
• What are the possible surgical complications, risks, and long-term outcomes?
• How many thoracic outlet decompression surgeries have you personally performed?
• What percentage of your patients experience symptom recurrence, persistent pain, or require revision surgery?
• What does your post-operative rehabilitation program include?
• What are your published or tracked long-term success rates for patients with neurogenic thoracic outlet syndrome and vascular thoracic outlet syndrome?

You may still feel tempted to ask the senior staff physician to perform your entire surgery. Don't be surprised if there is resistance or the surgeon asks you to go to another hospital. Most attending physicians have a lot of confidence in their thoracic surgery, vascular surgery, neurosurgery, and orthopedic surgery teams because they trained them.

Also, you should ask the hospital what the statistics are for the success of its thoracic outlet surgery, first rib resection, scalenectomy, and thoracic outlet decompression surgery. Some hospitals, performing a large volume of thoracic outlet decompression procedures, vascular decompression procedures, and brachial plexus decompression surgeries, do short- and long-range outcome studies and publish them. Many of these studies are easily found by going to the

This is important for you to read so you can advise your patients.

National Institutes of Health, US National Library of Medicine, PubMed, www.pubmed.gov or www.ncbi.nlm.nih.gov/pubmed/ and do a search of thoracic outlet surgery outcomes, thoracic outlet decompression outcomes, first rib resection outcomes, scalenectomy outcomes, thoracic outlet surgery success rates, and long-term surgical outcomes.

Many of them are free, and many more cost as much as this entire book ($35–$40) to simply read for 24 hours. The research costs involved in writing a book like this or preparing a simple 45-minute lecture at a medical conference can be staggering.

It would be worth spending a few hundred dollars obtaining studies to identify the best thoracic outlet surgeon, vascular surgeon, peripheral nerve surgeon, or multidisciplinary thoracic outlet center to perform your surgery. You could also do a phone consultation with me to discuss your options. I'm here to help you.

How Surgical Success Is Measured

How do doctors and hospitals determine if a surgery is a success and the overall thoracic outlet surgery success rate?

You have to be nervous just prior to your consultation with a thoracic outlet surgeon, vascular surgeon, or neurosurgeon. You are possibly facing neck surgery, first rib resection, scalenectomy, or another thoracic outlet decompression procedure. Who knows if you will be pain free, have little to no improvement, or end up worse?

Doctors grade the success rate of a surgery based on the relief of symptoms. This is the current rating system doctors use to determine if your surgery is a success.

Excellent Result

Excellent was defined as relief of all symptoms (90–100 percent improvement, complete symptom relief, excellent surgical outcome).

Good Result

Good was defined as significant reduction in most symptoms with some symptoms remaining (60–90 percent improvement, good surgical outcome, partial symptom relief).

Fair Result

Fair was defined as relief or reduction in some symptoms with persistence of some major symptoms (20–60 percent improvement, moderate surgical outcome, persistent symptoms).

Poor Result

Poor or failed indicated not enough improvement to have made the operation worthwhile or symptoms were worse (less than 20 percent improvement, failed surgery, persistent pain, continued nerve compression, recurrent symptoms) (27).

You are about to see the surgeon to determine whether thoracic outlet decompression surgery, first rib resection, or scalenectomy could reduce your pain and suffering. You are obviously nervous. Just then the nurse walks in and says, "Hey, don't worry, our doctors have a 90 percent success rate for thoracic outlet surgery."

Surgical Success Rates: Looking Beyond the Numbers

You are somewhat relieved, right? Not so fast. What does "successful thoracic outlet syndrome surgery", thoracic outlet surgery outcomes, or long-term surgical success really mean?

One study determined 90 percent of hospital surgeries were a success (46). The way they determined success was by asking their patients to fill out a questionnaire that asked them to grade their perception of pain relief, symptom improvement, and functional recovery. The procedure was considered a success if the patient reported an excellent, good, or fair result (46).

When you read the study, you find that 3 patients had excellent results, 32 had good results, 19 had fair results, and 6 had poor results or the surgery failed to show any improvement or they were worse (46).

Now the question I have for you is this: "Do you consider a successful surgery to be the relief or reduction of some symptoms while major symptoms, chronic pain, numbness, tingling, weakness, or functional limitations continue to persist?"

If not, then your perception of a successful surgery is what 35/60 patients stated. To you, this surgery was only 58 percent successful, or just a little over half of the surgeries were successful. Flip a coin.

In another study, they considered the surgery to be 78 percent successful. When you take a closer look, you see that 21 percent had complete relief, 32 percent had good relief, 25 percent had fair relief, and 22 percent had no relief or poor relief. When you recalculate the true success of the surgery, you must remove those patients with fair results. The result is that 47 percent were failures (47).

Out of the 37 studies I reviewed that determined the success of thoracic outlet decompression surgery, first rib resection, scalenectomy, and other thoracic outlet surgical procedures, there was only one study that considered the operation a success only if the patient was pain free after surgery (32). Before you believe everything they say, you might want to ask them how they determined what a successful surgery was.

The rating that is missing is "worse after surgery."

Not one of these studies documented those patients' outcomes using this rating system or referenced the number of patients whose pain increased, whose neurological symptoms worsened, or whose functional disability became worse after conservative care or surgery.

I only found one study that referenced the number of patients who were worse after surgery or conservative treatment.

This study found that patients undergoing surgery had missed more work time than those undergoing conservative management, physical therapy, and nonsurgical treatment. Nine out of fifteen patients (60 percent) who had surgery went back to work. They compared that to fifty out of sixty patients (78 percent) who received conservative treatment and returned to work (45).

These are the statistics for surgery versus conservative treatment. Results of surgery to treat thoracic outlet compression:

• 7 percent complete resolution of pain
• 27 percent marked improvement
• 50 percent minimal improvement
• 13 percent no improvement
• 13 percent worse

Total patients who had minimal improvement, persistent symptoms, no improvement, or worsening symptoms was 76 percent.

So, if you do not agree that a successful surgery means you still have the major symptoms you had before the surgery, then these published success rates should be interpreted much more carefully.

This should be how doctors should determine what is a successful surgery.

Successful Surgery

• Excellent was defined as complete relief of all symptoms, full functional recovery, and 90–100 percent improvement.
• Good was defined as significant reduction in most symptoms with some symptoms remaining, improved daily function, and 60–90 percent improvement.

Failed Surgery and Long-Term Surgical Outcomes

• Fair was defined as relief or reduction in some symptoms with persistence of some major symptoms (20–60 percent improved). • Failed indicated not enough improvement to have made the operation worthwhile or symptoms were worse (<20 percent improved). • Worse than before the surgery.

Long-Term Outcomes of Thoracic Outlet Syndrome Surgery

What are the long-term outcomes of thoracic outlet syndrome surgery, thoracic outlet decompression surgery, and first rib resection?

What if you had a friend who just had thoracic outlet syndrome surgery, was pain free, and said her surgeon had an 86.6 percent success rate two months after surgery? Excited to try thoracic outlet decompression surgery?

What is considered a successful thoracic outlet syndrome operation will surprise you, and short-term success doesn't last. The numbers of patients who fall back into chronic neck pain, shoulder pain, arm pain, numbness, tingling, and nerve compression symptoms after surgery are quite substantial, and this is a trend that happens in every study (47).

One study reported the results of thoracic outlet syndrome surgery on 254 patients with neurogenic thoracic outlet syndrome (NTOS). The follow-up post-surgery analysis initially reported an 86.6 percent success rate after two months. (1)

However, after 18 months, the success rate fell to 46.9 percent.

Eighty of those whose first thoracic outlet syndrome surgery was a failure were talked into a second revision thoracic outlet surgery to see if that would improve their suffering.

After a second surgery, only 45 of the 80 patients said they had a 50 percent improvement (1). The researchers considered a 50 percent improvement to be a success (31).

Would you consider a 50 percent improvement in pain relief, arm function, nerve symptoms, and quality of life a success?

Their conclusion was that there must be a minimum of an 18-month follow-up on patients and standardized definitions of surgical outcomes to determine the true effectiveness and long-term outcome of operative treatment for neurogenic thoracic outlet syndrome. (1)

However, after 72 months, the results bottomed out even worse at 36 percent (48).

So, if you see a post from your friend in a thoracic outlet syndrome support group, the Thoracic Outlet Syndrome Awareness Facebook group, or the NeuroTalk forum, excited about being pain free a few weeks after thoracic outlet syndrome surgery, just wait and see if she feels the same way in a year or so after the long-term surgical recovery period.

(1) Why Surgeons Recommend First Rib Resection and Scalenectomy—and Does It Prevent Blood Clots Like They Say?

Doctors recommend thoracic outlet decompression surgery because they believe the subclavian vein, subclavian artery, and brachial plexus nerves passing through the thoracic outlet are being compressed within a passage that has become too narrow. The surgical strategy is to enlarge this costoclavicular space, thoracic outlet passage, and neurovascular tunnel by removing the first rib and cutting or removing portions of the anterior scalene muscle and middle scalene muscle. This procedure is commonly called a first rib resection and scalenectomy. For patients with venous thoracic outlet syndrome, the goal is to reduce subclavian vein compression, improve venous blood flow, restore venous drainage, and reduce the risk of another upper-extremity deep vein thrombosis (UEDVT), also called Paget-Schroetter syndrome, effort thrombosis, or primary axillosubclavian vein thrombosis.

In 2020, Robert J. C. M. F. de Kleijn, Ludo Schropp, Jan Westerink, Gert J. de Borst, and Bart-Jeroen Petri published a systematic review titled, "Timing of Thoracic Outlet Decompression after Thrombolysis for Primary Upper Extremity Deep Venous Thrombosis," in the Annals of Vascular Surgery. The research team was based at University Medical Center Utrecht in the Netherlands and included specialists from the Departments of Vascular Surgery and Vascular Medicine, including vascular surgeons, an internist specializing in vascular medicine, and experts in the treatment of venous thoracic outlet syndrome, deep vein thrombosis, and vascular compression disorders. The review included six published studies involving 126 patients. Eighty-seven patients underwent early thoracic outlet decompression within two weeks after catheter-directed thrombolysis, while 39 underwent delayed decompression surgery more than two weeks later.

Even after first rib resection, thoracic outlet decompression surgery, and scalenectomy, recurrent blood clots, venous thrombosis, and subclavian vein thrombosis still occurred. Postoperative recurrent thrombosis was reported in 13% of patients who underwent early surgery and 21% of patients who underwent delayed surgery. These findings demonstrate that removing the first rib and dividing the scalene muscles did not eliminate the risk of another deep vein thrombosis, venous blood clot, or recurrent thrombosis. Patients should also understand that a procedure intended to improve venous blood flow, reduce venous compression, and decrease the risk of recurrent thrombosis does not guarantee complete relief from chronic pain, neck pain, shoulder pain, arm pain, arm numbness, hand tingling, muscle weakness, arm swelling, or other persistent symptoms. Removing muscles and bone may enlarge the passage for the subclavian vein, but it is not the same as proving that every source of pain, nerve compression, vascular compression, or functional disability has been corrected.

• de Kleijn, Robert J. C. M. F., Ludo Schropp, Jan Westerink, Gert J. de Borst, and Bart-Jeroen Petri. 2020. "Timing of Thoracic Outlet Decompression after Thrombolysis for Primary Upper Extremity Deep Venous Thrombosis: A Systematic Review." Annals of Vascular Surgery 66 (July): 654–661. https://doi.org/10.1016/j.avsg.2020.01.083. Abstract: https://pubmed.ncbi.nlm.nih.gov/32035261/

(2) First Rib Resection and Scalenectomy Do Not Guarantee Freedom from Pain or Future Blood Clots

Surgeons often recommend thoracic outlet syndrome surgery, specifically first rib resection and scalenectomy, for people with venous thoracic outlet syndrome (VTOS). The goal of this surgery is to remove the first rib and parts of the anterior scalene and middle scalene muscles to create a larger opening around the subclavian vein. The hope is that this extra space will reduce blood vessel compression, improve blood flow, and lower the risk of another blood clot. To find out how well this surgery works, Georgios Karaolanis, MD, MSc, PhD, a vascular surgeon and researcher from the University Hospital of Ioannina and the University of Ioannina School of Medicine in Greece, led a systematic review and meta-analysis published in 2021. His team reviewed 25 studies involving 1,511 patients with Paget-Schroetter syndrome, also called effort thrombosis or axillary-subclavian vein thrombosis. Of these patients, 1,293 (85.6%) underwent thoracic outlet decompression surgery, including first rib resection and scalenectomy.

The results are important for anyone considering thoracic outlet syndrome surgery. The study found that 22.61% of patients developed another blood clot after treatment. In other words, about 1 out of every 5 patients experienced a recurring blood clot, even after first rib resection and thoracic outlet decompression surgery. The researchers also reported that 3.7% of patients suffered a nerve injury related to the operation. While the surgery may improve blood flow and reduce compression of the subclavian vein in many patients, it does not guarantee that another clot will never occur.

Perhaps the most important question for patients is this: Will thoracic outlet syndrome surgery guarantee that I will be pain free? Based on this research, the answer is no. Although many patients improve after first rib resection and scalenectomy, the surgery does not guarantee complete pain relief, complete recovery, or protection from future blood clots. Before deciding on this invasive procedure, patients should understand that the purpose of surgery is to create more space for the blood vessels by removing bone and muscle—not to guarantee the complete elimination of pain. This is an important distinction to understand when weighing the potential benefits, risks, and long-term outcomes of thoracic outlet syndrome surgery.

• Karaolanis, Georgios, Constantine N. Antonopoulos, Stylianos G. Koutsias, Alexandros Giosdekos, Efstathios K. Metaxas, Petros Tzimas, Gert J. de Borst, and George Geroulakos. 2021. "A Systematic Review and Meta-Analysis for the Management of Paget-Schroetter Syndrome." Journal of Vascular Surgery: Venous and Lymphatic Disorders 9, no. 3 (May): 801–810.e5. https://doi.org/10.1016/j.jvsv.2021.01.011. Abstract: https://pubmed.ncbi.nlm.nih.gov/33540134/

(3) What Does the Research Say About Surgery for Venous Thoracic Outlet Syndrome (Paget-Schroetter Syndrome)?

Study Overview

In 2021, Dr. Karl A. Illig and his colleagues—published a study in the Journal of Vascular Surgery evaluating surgery for Paget-Schroetter syndrome, a form of venous thoracic outlet syndrome in which a blood clot forms in the subclavian vein. The study was conducted at the Indiana University School of Medicine and reviewed the outcomes of 125 first rib removal surgeries performed in 123 patients between 2007 and 2018. The researchers wanted to determine how well a combination of clot-dissolving treatment (catheter-directed thrombolysis), first rib removal (first rib resection), and additional catheter-based procedures when necessary restored normal blood flow and helped prevent future blood clots.

Study Results

The researchers found that surgery was very effective at restoring blood flow through the subclavian vein, but it did not completely prevent future blood clots. Of the 125 surgeries, 23 patients (18.4%) required an additional catheter-based procedure after surgery because blood flow through the vein was not normal. Of those 23 patients, 19 (15.2% of all surgeries) developed another blood clot after surgery, while the remaining 4 patients needed additional treatment because the vein remained narrowed or a small amount of clot was still present. These findings show that first rib removal surgery alone was not enough to prevent recurrent blood clots in every patient, and some patients required further treatment to restore normal circulation.

Clinical Conclusions

The researchers concluded that thoracic outlet decompression surgery, when combined with catheter-directed clot removal and additional catheter-based treatment when needed, is an effective way to restore long-term blood flow through the subclavian vein in patients with venous thoracic outlet syndrome (Paget-Schroetter syndrome). They also found that many patients in the later years of the study did well without long-term blood-thinning medication (anticoagulants) after surgery. However, the study also showed that approximately 1 out of every 6 patients still required additional treatment because of a recurrent blood clot or persistent narrowing of the vein. These findings suggest that surgery can be highly effective, but patients should understand that it does not guarantee that another blood clot will never occur and that careful follow-up after surgery remains important.

Dr. Karl A. Illig with Dr. Robert W. Thompson, Dr. Julie Ann Freischlag, Dr. Dean M. Donahue, Dr. Sheldon E. Jordan, Dr. Ying Wei Lum, and Dr. Hugh A. Gelabert, wrote the book Thoracic Outlet Syndrome— Illig, Karl A., Peter J. Doyle, George W. Rigberg, Hugh A. Gelabert, and Robert W. Thompson. "Management and Outcomes of Venous Thoracic Outlet Decompression: A Transition to the Infraclavicular Approach." Journal of Vascular Surgery 73, no. 4 (2021): 1313–1323. https://doi.org/10.1016/j.jvs.2020.05.076. PMID: 32497616. (pubmed.ncbi.nlm.nih.gov) https://www.jvascsurg.org/article/S0741-5214(20)31521-4/fulltext

Three Choke Points, Not One

After treatment for venous thoracic outlet syndrome (Paget-Schroetter syndrome), many patients are told that the next step to reduce the risk of another subclavian vein blood clot is first rib resection combined with scalenectomy (removal of the scalene muscles). This operation is designed to enlarge the interscalene triangle, one of the three recognized anatomical choke points where the subclavian vein or brachial plexus can become compressed. While this operation can be very effective when compression truly originates at this location, it addresses only one of the three potential choke points that can reduce blood flow through the thoracic outlet.

Choke Point #1 – The Interscalene Triangle

The first choke point is the interscalene triangle, where the anterior scalene and middle scalene muscles attach to the first rib. If these muscles become chronically tight, they can elevate the first rib and narrow the space available for the subclavian vein, subclavian artery, and brachial plexus. This is the area targeted during first rib resection and scalenectomy, making these procedures appropriate when the compression truly originates within the interscalene triangle.

Choke Points #2 and #3 – The Shoulder Compression Zones

In our clinical practice, we have found that the majority of our TOS patients have what we call Shoulder Thoracic Outlet Syndrome (Shoulder TOS) rather than primary compression within the interscalene triangle. In these patients, the primary choke points are the costoclavicular space (Choke Point #2) and the pectoralis minor space (Choke Point #3). We believe this pattern is largely the result of today's modern lifestyle, where prolonged shoulder flexion is required to operate a computer mouse, use a cell phone, type on a keyboard, and perform other repetitive forward-reaching activities. Over time, these positions can create chronic muscle shortening and increased downward pull on the shoulder.

Unlike the interscalene triangle, these shoulder choke points are influenced by multiple muscles, including the pectoralis minor, subclavius, short head of the biceps, coracobrachialis, and the middle fibers of the triceps. Together, these muscles can pull the shoulder downward into the thoracic outlet, narrowing the space available for the subclavian vein. Because these muscles are essential for lifting, reaching, pushing, pulling, and stabilizing the shoulder, they cannot simply be removed surgically without severely compromising normal shoulder function.

Why Pectoralis Minor Surgery May Not Be Enough

Some surgeons recommend pectoralis minor release (pectoralis minor tenotomy or resection) when compression appears to occur beneath the pectoralis minor tendon. However, in our experience, the pectoralis minor is only one of several muscles capable of pulling the shoulder downward into the thoracic outlet. Even if the pectoralis minor is released, persistent tension in the subclavius, short head of the biceps, coracobrachialis, and other shoulder muscles may continue to narrow the thoracic outlet. As a result, compression at Choke Points #2 and #3 may persist despite surgery.

A More Comprehensive Strategy

For this reason, the treatment approach presented in this book focuses on evaluating all three choke points, not just the interscalene triangle. The goal is to identify which muscles are producing the compression and then restore normal muscle tone, shoulder position, rib cage mechanics, and posture without removing structures that are critical for normal shoulder function. Rather than surgically removing ribs or muscles, this approach is designed to reduce abnormal muscle tension affecting up to 12 muscles that influence the thoracic outlet. From this biomechanical perspective, restoring normal shoulder mechanics and relieving compression at all three choke points provides a more comprehensive strategy for improving subclavian vein blood flow, reducing venous compression, and lowering the risk of recurrent blood clots than procedures directed at only a single choke point.

Do Surgeons Expect Complete Pain Relief After Surgery?

Do surgeons think that you should be completely pain free after first rib resection, scalenectomy, or thoracic outlet decompression surgery?

Surgeons don't expect patients to be completely pain free after surgery. In fact, one of the top surgeons who specializes in thoracic outlet syndrome stated, "A good result from surgery generally means improvement, not total cure. Most patients with good results experience fewer, less intense, and less frequent symptoms, but it is rare to observe complete symptom relief" (49).

Also, it appears patients are ok with results that leave them in chronic pain, persistent pain, residual symptoms, or ongoing nerve pain.

For instance, a retrospective chart review of 29 patients (36 operations) was performed by the Department of Surgery, Section of Vascular Surgery, the University of Iowa Hospitals and Clinics, Iowa City.

The study revealed that 85 percent of the patients would have the same surgery again for relief of thoracic outlet syndrome. Exactly 27 percent were still pain free. More than 70 percent still had recurring pain, persistent symptoms, residual arm pain, neck pain, shoulder pain, hand numbness, tingling, or, worse yet, they say they would do the surgery again (50).

Would you be able to live in chronic pain, persistent nerve pain, arm numbness, hand tingling, and shoulder pain, or would you seek a second surgery?

Recurrent symptoms develop in 15–20 percent of patients undergoing either first rib resection, scalenectomy, or thoracic outlet decompression surgery for thoracic outlet syndrome.

In this study, 97 patients were operated on a second time because their symptoms of thoracic outlet syndrome returned after the first surgery.

The results were that 84 percent of the surgeries were successful in the first three months. After five years, this dropped to 50 percent or half were successful. After 10 years, the number of patients with successful surgeries bottomed out at 41 percent.

If you have already had thoracic outlet surgery, first rib resection, or scalenectomy, and it failed to give you relief, the choice of having a second surgery can be a tough one.

Government Research on Surgical Outcomes

What government studies have been done to determine the success of thoracic outlet syndrome surgery, first rib resection, and scalenectomy?

There was a study done in 2000 to determine the success of thoracic outlet syndrome surgery, titled "Outcome of Surgery for Thoracic Outlet Syndrome in Washington State Workers' Compensation" (44).

This study was done to determine the success of patients who had surgery for thoracic outlet syndrome following a work-related injury, occupational injury, or workplace trauma.

The study determined that patients with thoracic outlet syndrome caused by trauma, repetitive strain injuries, or work-related injuries were more likely to have poor outcomes after surgery.

In 2000, the Department of Environmental Health, University of Washington School of Public Health and Community Medicine published the results of a survey of the outcomes of surgery for thoracic outlet syndrome on injured workers. The outcomes of these surgeries were determined by telephone survey an average of 4.8 years after their surgery.

According to the survey, one year after the surgery, 66 percent were still on disability. Two years after surgery, 40 percent were still receiving workers' compensation disability or work disability benefits. Sadly, five years after surgery, 44 percent of patients reported not working.

Of the only 44 percent of the workers who were gainfully employed, 61 percent were "limited a lot" in vigorous activities. So just by saying the surgery was a success because the injured worker was able to return to work is a gross understatement. Many workers who go back to work after surgery work through chronic pain, persistent symptoms, neck pain, shoulder pain, arm pain, hand numbness, or require pain medication and painkillers just to get through the day.

The strongest predictors of whether the surgery would fail were the number of days they were off work in the six months before surgery and their age. The other strong predictor that the surgery would fail for thoracic outlet syndrome was how long it took for the doctors to correctly diagnose them with thoracic outlet syndrome after the injury. I guess if you aren't diagnosed quickly, you are off work for a longer period of time, allowing chronic nerve compression, muscle dysfunction, scar tissue formation, and long-term disability to become more established.

Poor Surgical Outcomes in Chronic and Misdiagnosed Cases

By the time patients get to me, they have oftentimes had thoracic outlet syndrome, neurogenic thoracic outlet syndrome, chronic nerve compression, brachial plexus compression, upper extremity nerve entrapment, and compression neuropathy for several years, have been misdiagnosed several times, have had a few unnecessary surgeries, and I was their last resort before surgery. So I'm used to treating patients who have had chronic thoracic outlet syndrome, persistent nerve compression, and long-standing upper extremity pain for months and even years. They are more difficult cases to turn around, but they eventually get better and so far I haven't referred one patient to surgery.

Whether they returned to work or not, 61.2 percent reported they were experiencing their worst preoperative symptom "a lot" and surprisingly, approximately 20 percent of patients might have new adverse outcomes, primarily related to new neurologic complications, nerve injuries, persistent neurological symptoms, and chronic pain complaints.

Workers with thoracic outlet syndrome who received surgery had substantially (50 percent) greater medical costs, were more than three times as likely to be work disabled, have long-term disability, and experience reduced functional capacity 1.8 years following thoracic outlet syndrome diagnosis, and were more than four times as likely to be work disabled 2.8 years after thoracic outlet syndrome diagnosis than workers with thoracic outlet syndrome who did not receive surgery.

A follow-up report published in 2015 by the Washington State Department of Labor and Industries determined that work-injured patients' outcomes were not so good for thoracic outlet decompression surgery, first rib resection, and scalenectomy performed for thoracic outlet syndrome (50).

Outcomes Following Surgery for Neurogenic Thoracic Outlet Syndrome

Outcomes of surgery for neurogenic thoracic outlet syndrome, brachial plexus compression, and upper extremity nerve compression disorders in workers' compensation are poor in a majority of patients, partly due to nonspecific diagnosis, inaccurate diagnosis, and failure to establish objective diagnostic criteria.

Other terms that describe specificity are not an exact diagnosis, not a precise diagnosis, not a definitive diagnosis, an inconclusive diagnosis, or a nonspecific diagnosis.

The diagnosis and treatment of neurogenic thoracic outlet syndrome, brachial plexus compression syndrome, and compression neuropathies is highly controversial and associated with thoracic outlet surgery, first rib resection, and scalene muscle surgery based on no clear evidence of the presence of true thoracic outlet syndrome.

Considering the poor outcomes reported from the surgical management of neurogenic thoracic outlet syndrome, brachial plexus disorders, and upper extremity nerve compression syndromes in most workers' compensation cases, this guideline requires objective evidence of brachial plexus injury, brachial plexopathy, or brachial plexus disorder, including abnormal electrodiagnostic testing, nerve conduction studies (NCS), and electromyography (EMG) findings.

After surgery, 20 percent of patients experienced a new adverse event, primarily related to new neurological complications, nerve dysfunction, lung complications, and pulmonary pathology, the most serious of which is phrenic nerve dysfunction, phrenic nerve injury, and diaphragm paralysis.

The study also revealed that evidence does not support the use of anterior scalene muscle blocks, scalene injections, or local anesthetic scalene blocks to diagnose neurogenic thoracic outlet syndrome, and evidence does not support the use of botulinum toxin (Botox) injections, botulinum toxin therapy, or Botox scalene injections to diagnose neurogenic thoracic outlet syndrome (51).

Return to Work After Thoracic Outlet Surgery

How soon before you can return to work?

A study of the outcomes of thoracic outlet syndrome surgery, performed by the Department of Surgery at the University of Michigan Hospitals, found that patients returned to work about 10 months after surgery. The study reported that 86 percent of patients were moderately to highly satisfied with their surgical outcome, but only 55 percent of the patients had returned to full-duty work. Still, 45 percent did not return to full duty, so as long as they did not have to work, they were satisfied with the surgery. If they had to return to work, however, they often had to work through persistent pain, chronic pain, and ongoing symptoms. So how do you do that? Of those patients, 9 percent were taking narcotic pain medications (opioids) and 30 percent were still taking nonsteroidal anti-inflammatory drugs (NSAIDs).

After 47 months, only 65 percent of those patients reported improved pain relief and improved function. While 35 percent of patients remained on pain medication, 18 percent of patients were disabled (52). The answer is that there is no guarantee when you can return to work or whether you will ever be able to work again after thoracic outlet decompression surgery.

Long-Term Opioid Use After Surgery

So, what is the percentage chance that I could become reliant on opioid pain medication to cope with the pain after surgery?

For many patients who undergo thoracic outlet surgery, their only hope of being pain free after surgery is with narcotic painkillers, opioid analgesics, or prescription pain medication. In a survey of patients more than 100 months after surgery for thoracic outlet syndrome, 27.3 percent required continued postoperative narcotic analgesics (53), demonstrating the risk of long-term opioid use after surgery.

What success did surgery for thoracic outlet syndrome have in getting patients off dangerous opioid painkillers?

One study compared how many patients could cope with pain without opioids before and after surgery and how many patients were able to discontinue opioid medications because of the surgery (54).

— 85 (55.2 percent) did not require opioid pain medication for thoracic outlet syndrome symptoms before surgery.

— 69 (44.8 percent) required opioid medications to cope with thoracic outlet syndrome symptoms before surgery.

By three months after thoracic outlet syndrome surgery, the surgical incisions should have healed, and ideally patients would have transitioned from opioid pain medications to an over-the-counter anti-inflammatory medication such as an NSAID.

Three months after surgery these were the results:

— 53 (34.2 percent) did not require opioid pain medication for thoracic outlet syndrome symptoms after surgery.

— 101 (65.6 percent) required opioid pain medication to cope with thoracic outlet syndrome symptoms after surgery.

Also, three months after surgery, the number of patients taking strong opioid medications more than tripled from 21 to 74.

So, the result of surgery was that more patients who previously did not require opioids now required opioid pain medication, and patients who had been taking opioids before surgery often required higher opioid dosages, stronger narcotics, or long-term opioid therapy.

Six months after surgery, here are the results:

— 81 (52.6 percent) did not require opioid pain medication for thoracic outlet syndrome symptoms after surgery.

— 73 (47.2 percent) required opioid pain medication to cope with thoracic outlet syndrome symptoms after surgery.

So, after 154 patients underwent thoracic outlet syndrome surgery, only 4 patients were able to discontinue opioid medications within six months. The remaining 73 patients still required opioid painkillers to cope with their pain.

And 73 (47.2 percent) of the patients were still using moderate- to high-strength opioid medications six months after surgery. Also, twice as many patients were taking strong opioid pain medications six months after surgery than before surgery (54).

Risk of Opioid Dependence and Addiction

If you start taking opioid pain medications immediately after surgery, what is the chance you could become reliant on long-term opioid therapy or develop an opioid addiction?

An article published in Newsweek in March 2017, titled "CDC Study Finds Opioid Dependency Begins Within a Few Days of Initial Use," asked the question:

"At what point does the use of painkillers move from medical care to addiction?" (55)

According to the Morbidity and Mortality Weekly Report, researchers from the Centers for Disease Control and Prevention (CDC) and the University of Arkansas for Medical Sciences examined patient records from the IMS LifeLink+ database between 2006 and 2015. They found that the transition from an initial opioid prescription to chronic opioid use begins surprisingly early. Even a one-day opioid prescription carried a 6 percent risk of continued opioid use one year later and a 2.9 percent risk of continued use three years later (56).

The patients most likely to develop long-term opioid dependence were those who received a one-week opioid prescription. More than 13.5 percent were still taking opioid pain medications one year later if they had taken them for more than one week. Approximately 30 percent developed opioid dependence or addiction if they continued taking opioids for more than one month (56).

So, it is fair to say that the pain resulting from thoracic outlet syndrome surgery can contribute to opioid dependence, long-term opioid use, and opioid addiction.

Is there a way to avoid taking dangerous opioid pain medications?

There are not many options left after surgery has failed to relieve your pain. We have already discussed the option of painkillers, opioid medications, and NSAIDs for temporary pain relief.

Spinal Cord Stimulation (SCS) for Chronic Pain

Doctors who have patients with failed spine surgery, failed back surgery syndrome (FBSS), or chronic neuropathic pain can surgically implant a spinal cord stimulator (SCS) unit into your body. They implant the remote-controlled neuromodulation device and run electrical stimulation leads through your spinal canal to attach to your spinal cord.

The transcutaneous electrical nerve stimulation (TENS) unit and spinal cord stimulation (SCS) systems deliver electrical impulses to the spinal cord. The stimulation interrupts the feeling of pain, substituting a sensation called paresthesia (pins and needles). You receive a remote-control device that allows you to increase or decrease the electrical stimulation delivered through the implanted neurostimulator.

Doctors say it might reduce chronic pain a little, so you don't have to take as many pain medications, prescription painkillers, or opioid medications in the short term, although dosages often increase as you develop a tolerance to these medications. This can send you down the dangerous opioid painkiller road, lit

Doctors say it might reduce chronic pain a little, so you don't have to take as many pain medications, prescription painkillers, or opioid medications in the short term, although dosages often increase as you develop a tolerance to these medications. This can send you down the dangerous opioid painkiller road, lit with chronic pain and suffering.

There are several clinical studies that support the use of spinal cord stimulation (SCS) in thoracic outlet syndrome patients who continue to experience chronic pain, intractable pain, persistent nerve pain, and neuropathic pain after failed surgery. The main limitation is that this approach treats the pain symptoms rather than the underlying cause of thoracic outlet compression. It does not reduce muscle spasms, restore normal biomechanics, reduce brachial plexus compression, or decompress the thoracic outlet.

A More Logical First Step—Non-Surgical Thoracic Outlet Syndrome Treatment

I want to make one thing very clear: I have never had a patient I could not help and have never referred one patient for thoracic outlet syndrome surgery, including patients who previously had thoracic outlet surgery, first rib resection, or scalenectomy.

If you have thoracic outlet syndrome or suspect you might have it, please contact me at www.teamdoctors.com or www.thoracicoutletsyndrome.org before considering surgery. If I can help more patients avoid unnecessary surgery, unnecessary medications, unnecessary injections, and unnecessary procedures, then this book has already been worth writing.

When the true cause of thoracic outlet syndrome is identified and appropriately treated, most patients can achieve substantial relief without surgery. The key is understanding the underlying mechanical cause of brachial plexus compression, subclavian artery compression, and subclavian vein compression, and addressing all of it through a comprehensive, evidence-informed, non-surgical treatment approach.

Now spring forward to learn what actually works and why!