When in Doubt, Cut It Out?

The cure for a muscle spasm is not to cut it out of the body.

—James Stoxen

Well, we tried everything, so now what?

Surgery?

You tried conservative therapy, but after three weeks to three months a few of the 16 different nonsurgical options fail to produce long-term reduction in the compression on the thoracic outlet and long-term reduction in pain and suffering, you are referred to a surgeon. You’ve tried everything, so I guess it’s time to do surgery.

What does the medical community recommend as a minimum conservative therapy before considering surgery?

One doctor at Johns Hopkins recommends an eight-week protocol of physical therapy before referring the patient for surgical evaluation of neurologic thoracic outlet syndrome (1). When do doctors and patients consider 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 on their thoracic outlet, and that is surgery. “When in doubt, I’ll just have the surgeon 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 makes you feel so miserable, for so long, that you’ll do anything! You can’t think that way!

The 10 Reasons Doctors/Patients Consider Surgery for TOS

After reviewing more than 2,300 scientific papers, citations, articles, and books, I’ve come across these seemingly possible reasons your doctor might recommend surgery as the next step.

1. Paget-Schroetter syndrome

2. Thrombosis—post-subclavian vein thrombosis—vessel reconstruction

3. Arterial compression

4. Limb-threatening complications

5. Long-term compression

6. Completed and successful initial treatment of subclavian vein thrombosis

7. Neurologic deficit—weakness and decreased sensation

8. Intractable pain

9. Surgery performed for all the wrong reasons

10. Failure of a carefully supervised physical therapy program

1. Paget-Schroetter Syndrome

Effort thrombosis, or Paget-Schroetter syndrome, is a blood clot in your subclavian vein that happens with strenuous and repetitive activity of the upper extremities (2). A majority of patients report a discrete precipitating event, usually sports-related arm exertion. Occasionally, minor and relatively innocuous day-to-day activities can precipitate effort thrombosis (3). Paget-Schroetter syndrome (PSS) is often regarded as the most common vascular problem in athletes (4).

Paget-Schroetter syndrome is an outcome of venous thoracic outlet syndrome caused by a vein obstruction with a blood clot in the vein. They all don’t release and most can be treated with clot- buster drugs, but for those that do, you are headed for the operating table.

This is not a type of thoracic outlet syndrome. It is a condition that is a complication of thoracic outlet syndrome. When you have a clot form in the subclavian vein, there are protocols to follow to remove or break up the clot, then to remove the external compression on the neurovascular bundle that caused the clot.

Here are the steps to approaching this condition.

• The examination reveals signs of a clot.
• The doctors will order the appropriate diagnostic tests.
• If the tests show there is a clot, the doctors will consider anticoagulation medication.
• Catheter-directed thrombolytic therapy is when a catheter is inserted into your vein and clot- busting medication is released in the vein to dissolve the clot.
• Thrombectomy, embolectomy, venoplasty—After the clot is removed, the doctors repair the damaged vein.

Now that the clot is dissolved, you can take a breather and determine if you want the doctors to remove the scalene muscles, pectoralis muscle, and first rib, because regardless of what they tell you, there is still a chance that we can decompress this area without surgery.

This is the surgical route the doctors recommend within 24 hours of the removal of the clot.

• Surgical removal of one or two scalene muscles, and the first rib
• Adjunctive endovascular balloon angioplasty (5)
• Stenting in improving axillo-subclavian vein patency (5) In most cases, thrombolytic therapy is able to effectively dissolve the clot (6). It is most effective when given within one week of the onset of symptoms, but might be effective up to one month after symptoms develop (7).

Catheter-directed thrombolysis involves cutting a hole in the vein and sliding a tube or catheter in the vein, which releases drugs in the vein to break up the clot. The movement of the catheter into the vein is associated with several disadvantages, including major systemic bleeding (8–9).

The goal of thrombolysis (dissolving the clot) is to clear any fresh or recent clot from the axillary and subclavian veins, along with any occluded, smaller, adjacent veins that have been allowing the blood to flow around the blocked major vein. This usually results in a marked improvement in the venographic appearance and a prompt reduction in symptoms of venous obstruction (10).

Remove the Compression without Surgery

There are examples where patients had Paget-Schroetter syndrome that was treated successfully with catheter-directed thrombolysis, followed by anticoagulant therapy with no surgery required (11).

Gabrielle Collison is an incredible athlete I consulted with from London, England, who had a blood clot in her subclavian vein, which was successfully treated without surgery. She is now training harder than ever with no recurrence of thoracic outlet syndrome or clots years after.

Remove the Compression with Surgery

One study reported that patients treated surgically for Paget-Schroetter syndrome had better functional outcomes than those managed conservatively. Prompt thrombolysis and surgery was superior to delayed management with respect to rethrombosis (after a blood clot) and functional outcome. The medical records of patients treated for Paget-Schroetter for 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 care was provided. I have found most conservative care delivered in a hospital setting is not so successful because there is no one to adjust the ribs out of the outlet and do minimal deep tissue compared to what is required for a full release of the compression.

2. Thrombosis. Post-Subclavian Vein Thrombosis—Vessel Reconstruction

As the compression of the artery continues, it irritates the wall causing damage to the artery. This scar tissue in the wall of the inside of the artery can lead to turbulence in the blood flow, which can cause a blood clot, which can release from the artery wall as an embolus (13).

3. After Completed and Successful Initial Treatment of Subclavian Vein

Doctors recommend surgery after the subclavian vein experiences thrombosis. The surgery is to remove the compressive force that caused the vein to collapse under this compression. This is where you have the muscle spasms and abnormal positioning of the collarbone and the first rib that are causing the abnormal compressive force on the subclavian vein.

4. Arterial Compression

Arterial damage, causing ischemia of the limb, occurs in less than 5 percent of all instances of thoracic outlet syndrome (7).

Arterial thoracic outlet syndrome is defined as an objective abnormality of the subclavian artery caused by extrinsic compression and subsequent damage by an anomalous first rib or analogous abnormal structure (cervical rib or band) at the base of the scalene triangle (14). Of course, if there is a broken collarbone, which did not mend well leading to an aneurysm forming in the artery that is at risk of tearing open, or a blood clot in the vein that might release as an embolus and travel to the lung to infarct, then by all means this should be corrected with surgery. Aneurysms of the subclavian artery are rare, but they can present with devastating consequences that might lead to loss of the limb (8).

These severe arterial complications can also be the result of delayed therapy, and they can best be avoided by early recognition, diagnosis, and treatment (7).

5. Limb-Threatening Complications

More advanced scarring of the inside of the arterial wall can cause major artery thrombosis (blood clots) resulting in potentially limb-threatening ischemia. Limb-threatening ischemia is when the cells in your arm die because they cannot get any oxygen. If enough cells die, the arm tissue is considered dead and has to be surgically removed (13).

If your arm is blue, gray, or red, is extremely swollen and cold, you might have a clot that could cause a risk of losing a limb to amputation.

6. Long-Term Compression

Some patients end up this way because they were misdiagnosed. Others were underdiagnosed. They might have been diagnosed with carpal tunnel syndrome, had surgery for that, and their symptoms did not subside. Then maybe they were diagnosed with a herniated disc, had surgery for that, and still their symptoms did not subside.

Finally, after a few years, they are correctly diagnosed with thoracic outlet syndrome. However, by this time the scar tissue is thick in the area; the muscles and ribs are locked up with a layer of tough scar tissue that doesn’t make the repositioning of the ribs out of the outlet easy.

Other patients have been correctly diagnosed with thoracic outlet syndrome right away, but go to 10–15 or more different nonsurgical specialists before they finally just give up and have surgery.

Some patients just get worn down and tired of the long-term suffering with thoracic outlet syndrome.

Eventually, they make an appointment to see if the surgeon can operate to end their suffering.

One study done by the Department of Environmental Health, University of Washington School of Public Health and Community Medicine determined that a strong predictor that the surgery would fail for TOS was how long it took for the doctors to correctly diagnose the patient with thoracic outlet syndrome after the injury (15).

Many of my patients, like Sonny Burke, have had long-term compression of the thoracic outlet with considerable disability and still we were able to turn the case around. Learn more about Sonny Burke’s case on the TOS website at www.thoracicoutletsyndrome.org.

7. Neurologic Deficit—Weakness and Decreased Sensation

When patients have neurologic deficit or symptoms, such as numbness, tingling, shooting pain down the arm, or heaviness, they get nervous and run to the doctor or surgeon. Many go to their family doctor, who most likely refers them to a neurologist or neurosurgeon.

Patients don’t realize that if you remove the cause of nerve compression, the numbness, tingling, and radiating pain will subside. Even if you have compression of the deeper portion of the nerve, by removing the cause of nerve compression, the muscle wasting will reverse and strength will return with active rehabilitation.

So, patients who have neurologic deficit should get a second opinion on surgery.

8. Intractable Pain

Some doctors think it is medically necessary to do surgery on TOS patients with intractable pain (16).

Some surveys indicate that more than 40 percent of the adult population has chronic, recurrent pain.

There is a difference between chronic pain and intractable pain (17) (18). There are some people who suffer constant, excruciating, unrelenting pain.

9. Surgery Performed for All the Wrong Reasons

In a 2011 study in the Surgical Neurology International journal, two doctors from the Department of Neurological Surgery at The Albert Einstein College of Medicine evaluated 274 patients with neck and back complaints during a one-year period. Of the 274 consults, 45 patients were told they needed surgery by outside surgeons, although their neurological and radiographic findings were not abnormal (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, a survey showed that patients who do not have private insurance or workers’ compensation insurance are rarely diagnosed as having thoracic outlet syndrome. What the study also found was that Medicaid patients almost never undergo surgery. Could it be because Medicaid does not pay very well for these surgeries? (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 surgery for thoracic outlet. 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 do 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 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 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).

10. 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 approaches 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 approach and my human spring approach.

Everyone agrees... compression is the cause of thoracic outlet syndrome. When doctors say surgery is recommended for TOS, they have done everything medically possible to remove the cause of the compression of the 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 body and finally you will be pain free. Doctors call it surgical decompression.

What is involved in surgical decompression for thoracic outlet syndrome?

It’s neck, shoulder, and chest surgery involving the surgical removal of the muscles, which are too tight causing a compression of the thoracic outlet. What muscles and ribs are surgically removed from the area of compression of your thoracic outlet and tunnel?

1. The main surgery for TOS involves the surgical removal (surgical resection) of the anterior scalene muscle, the middle scalene muscle, and the first rib, because doctors think they are the cause of the compression of the interscalene triangle and the costoclavicular.

1. The less common surgery for TOS involves the surgical removal (surgical resection) of the pectoralis minor muscle, because doctors think it is cause of the compression of the costoclavicular space.
2. 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 ribs.

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

These are a several surgery approaches used to decompress the thoracic outlet. The main two are the transaxillary and the supraclavicular scalenectomy. The next most popular surgery is the pectoralis minor tenotomy.

• Supraclavicular scalenectomy
• Transaxillary
• Combined
• Endoscopic assisted transaxillary first rib resection
• Pectoralis minor tenotomy

Supraclavicular Surgical Approach

The entry for the supraclavicular surgery approach is at the top of the shoulder, and it produces a visible scar (26). The supraclavicular approach allows for a wide view of the subclavian artery.

The main goal of thoracic outlet surgery is to remove whatever is compressing the neurovascular bundle.

What doctors have concluded is that the main structures that are compressing the neurovascular bundle are the following.

• Anterior scalene muscle
• Middle scalene muscle
• First rib
• Cervical ribs

Resection of the First Rib

There is disagreement in the surgical community whether it is medically necessary to remove your entire first rib or a portion of it. Most surgeons have found that an incomplete resection might lead to a reoccurrence of symptoms of TOS after surgery. That is because scar tissue and calcium deposits can grow on the stump of the severed rib and cause irritation in the area or compression of the outlet again (15).

If the first rib floor is lifted up into the outlet/tunnel by the scalenes and you surgically remove that, what if the shoulder girdle roof is being pulled down by muscles into the thoracic outlet/tunnel causing compression? In that case you may still have thoracic outlet syndrome after the rib resection surgery.

Supraclavicular Surgical Approach

If there is damage to the phrenic nerve patients will experience some amount of reduction in lung capacity.

Then the doctor closes the opening and you go to recovery.

Transaxillary Surgical Approach

Resect The Anterior Scalene Muscle – They use what is called Metzenbaum scissors to cut the anterior scalene muscle from the first rib. The phrenic nerve runs across the surface of the anterior muscle so they have to be very careful not to cut it or you will have trouble breathing.

Resect The Middle Scalene – They use the Metzenbaum scissors to cut through the middle scalene muscle from its insertion on the first rib. When they cut through this muscle they must be careful not to cut through the long thoracic nerve as it passes directly through the middle scalene muscle. If this happens the serratus anterior muscle will no longer work causing a complication called a “winged scapula”.

Resect The First Rib – Now the rib is cut free from the attachment to the subclavius muscle and the attachment at the sternum or breastbone. After the first rib is cut they can trim off the rib by biting off pieces of it with the Kerrison rongeur.

Once the first rib is cut free from its top, bottom, front and back attachments, it is removed intact. Then the doctor closes the opening and you go to recovery.

Transaxillary Approach

This surgical approach begins with an incision in the armpit area. The surgeon then locates the first scalene muscles that will be surgically clipped out of the body. This produces less scarring, and the scar is less visible to the naked eye because it’s in the armpit.

The transaxillary approach does not permit performing vascular repair or surgical repair of your blood vessels in cases of subclavian artery pseudo-aneurysm (23). Aneurysms of the subclavian artery are rare, but they can present with devastating consequences that might lead to loss of the limb (24).

Patients with aneurysms needing arterial reconstruction require resection of the artery from a supraclavicular approach (25).

Pectoralis Minor Tenotomy

The pectoralis minor tenotomy is a surgical procedure to surgically remove the pectoralis minor muscle.

This is because either it is putting pressure on the blood vessels and nerves directly, it is dragging the shoulder down into the bundle, or both.

How do doctors determine if they are going to surgically resect the pectoralis minor, the anterior and middle scalene and first rib, or all of the above? In one study, the choice of operation was determined by responses to muscle blocks (injections).

Patients first had their pectoralis minor injected. If that relieved the majority of the symptoms of outlet compression, then the doctor would do the pectoralis minor resection. If the injection did not improve symptoms, then the doctor would inject the scalenes to see if that would reduce the symptoms. If the scalene injection caused the outlet compression symptoms to subside, the doctor would surgically remove the scalenes and the first rib (27).

Some doctors just surgically remove all three muscles and the rib, because they think it gives a better result statistically. If they don’t make the right diagnosis, they shouldn’t have to do a second surgery.

Another way of putting it is, “When in doubt, cut them all out.” In another study, patients who had only the pectoralis minor resected had better outcomes than the combination of the pectoralis minor, scalenes, and first rib removed. They determined that the success rates with a one- to three-year follow-up for the PM-alone group were 90 percent good–excellent, 2 percent fair, and 8 percent failed; for the combined group, success rates were 35 percent good– excellent, 19 percent fair, and 46 percent failed (27).

Pectoralis Minor Tenotomy

The lateral pectoral nerves pass through the pectoralis minor.

Surgical Removal of Cervical Ribs

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

If you are an adult who just recently came down with thoracic outlet syndrome, and you consulted with a doctor who noted that the evidence of cervical ribs on an X-ray was the cause of your pain, you know this is not true. That is because you have had these cervical ribs your entire life and they never bothered you.

Based on one doctor’s experience, symptomatic cervical ribs should not be considered pathology peculiar to the adult population. Although uncommon, children might present with symptomatic cervical ribs that necessitate surgical intervention (30).

I would not recommend the surgical removal of your child’s cervical ribs or the removal of any ribs, unless you have exhausted the protocols for the human spring approach for treatment I have listed in Chapter 13. Please call me if the doctor is recommending surgery for your child.

One study stated that all arterial TOS 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 results 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 Ribs Resected Following an Auto Accident or Work Injury

One study that surveyed patients eight years after the surgical removal of cervical ribs 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).

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 ribs that produced symptoms of TOS (33).

The conservative therapy consisted of physical therapy, including neck-stretching exercises, abdominal breathing exercises, posture correction, nerve glides, and, after 1998, the Feldenkrais Method. None of these therapies reduced the muscle spasms that compress the thoracic outlet, so these patients had no chance of improving.

The indications for surgery were disabling pain and paresthesia and failure to respond to conservative treatment.

• The failure rate for patients in whom symptoms developed after work-related injuries or repetitive stress at work was 42 percent.
• The failure rates for patients whose symptoms followed an auto accident 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 group was 75 percent, compared with a failure rate of 38 percent in the non-work-related group. 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 outlet during the accident. Apparently, the conservative treatment was not effective in reducing the muscle tension that was causing an elevation of the first rib. When the transaxillary first and cervical rib resections failed to end their suffering, seven of them were talked into another surgery (33).

They had another surgery to surgically remove the scalene muscles from their necks and to cut out the posterior rib stumps in seven patients. The rest got transaxillary first rib resections. Five of the eight operations (63 percent) failed to end their suffering after two surgeries (33).

Why do some cervical rib and rib resections fail?

One study reported on the reasons why cervical rib surgeries fail. One reported on 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 (29) (34). Which surgery offers the best result?

There was a study done in 1989, which compared the results of the transaxillary first rib resection approach to the supraclavicular first rib resection approach. Both methods of surgery had about the same result 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’s better to get the transaxillary first rib resection.

Operating Time

Arterial TOS takes the longest time to do the surgery, taking an average of 223.5 minutes (four hours) versus an average of 127 and 119 minutes (two hours) for venous and neurologic TOS, respectively (36).

Hospital Stay

Patients with arterial thoracic outlet syndrome required the longest in-hospital stay of up to six days. Patients with venous thoracic outlet syndrome required about five days of a hospital stay, and the patients with neurologic thoracic outlet syndrome required an average of two days in the hospital (36).

Hospital Costs

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 year 2005 dollars. Patients who had vascular thoracic outlet syndrome required significantly longer lengths of stay (7.7 versus 2.4 days) and higher total hospital charges of $53,373 versus $16,160 (37).

Complications of 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

1. Pneumothorax

2. Pleural Effusion

3. Postoperative Thoracic Duct Lymph Leak

4. Temporary Or Permanent Brachial Plexus

5. Phrenic Nerve

6. Long Thoracic Nerve Injury/Dysfunction

7. Subclavian Artery Injury

8. Subclavian Vein Injury

9. Postoperative Bleeding O

10. Wound Hematoma (Associated With Excessive Anticoagulation)

11. Residual Subclavian Vein Obstruction

12. Early Postoperative Rethrombosis

13. Late Postoperative Axillary Vein Obstruction

14. Late Postoperative Subclavian Vein Obstruction

1. Rethrombosis,
2. Recurrent Symptoms
3. Pneumothorax (Collapsed Lung)

A pneumothorax (collapsed lung) happens when air gets in the chest cavity that causes the lung to collapse. The symptoms are sudden chest pain, a tightness in the chest, shortness of breath, rapid breathing, a cough, a rapid heart rate, and fatigue. Because the first rib in the pleura of the lung is so close to the rib, when the rib is resected or surgically removed, you could get a pneumothorax. One author cited that more than 33 percent of patients had a pneumothorax after surgery (38).

2. Pleural Effusion (Water on the Lungs)

Patients can get pleural effusion as a complication of thoracic outlet surgery (10). Pleural effusion, or as it’s sometimes called “water on the lungs,” is when fluid leaks in between the layers of the membrane outside the lungs.

Symptoms are chest pain, dry cough, shortness of breath, or difficulty breathing, and the inability to breathe easily unless sitting straight up or standing, called orthopnea.

3. Postoperative Thoracic Duct Lymph Leak

The thoracic duct is the largest lymphatic trunk in the body which drains chyle and lymph from most of the body. It is a very thin walled and colorless vessel located close to the thoracic outlet so therefore because of this, it is prone to injury during surgery. In adults, the thoracic duct transports up to 4L of lymph per day. A large portion of the body’s lymph is collected by this duct and then drained into the bloodstream. It drains into the bloodstream in the thoracic outlet area near the brachiocephalic vein between the internal jugular and the left subclavian veins.

Lymph drains into the subclavian vein but blood from the vein is prevented from entering the thoracic duct because it is prevented from flowing backwards with valves.

A cervical CL can spread from the root of the neck into the mediastinum. With sufficient hydrostatic pressure, the collection of chyle may penetrate the pleural, forming a chylothorax, which presents clinically with shortness of breath, tachypnea, and chest pain. When the thoracic duct is blocked or damaged a large amount of lymph can quickly accumulate in the cavity around the lung called the pleural cavity. When this happens it is called a chylothorax. The condition is rare but serious.

A chyle leak can result in delayed wound healing, dehydration, malnutrition, electrolyte disturbances, and immunosuppression. Prompt identification and treatment of a chyle leak are essential for optimal surgical outcomes.

4. Brachial Plexus Injury.6% (37)

The brachial plexus is the network of nerves that sends signals from your spinal cord to your shoulder, arm and hand. A brachial plexus injury occurs when these nerves are stretched, compressed, or accidentally cut during surgery. Severe brachial plexus injuries can leave your arm paralyzed, with a loss of sensation.

Signs and symptoms can be moderate to mild such as little as an electric shock, burning sensation or numbness and weakness in the arm. In more severe cases the injury to the brachial plexus can be weakness or in certain muscles in your shoulder, arm or hand to a complete inability to move your arm and hand accompanied by either complete numbness, severe pain or both.

There is a risk of brachial plexus injuries, as a result of excessive retraction of the nerve trunks with metallic retractors or elastic tape (42). Transaxillary removal of the first rib carries an important risk of serious complications. Among these, brachial plexus injury is the most frequent one.

Even if yours seems minor, you may need medical care. Even with surgery, some people experience permanent muscle weakness or paralysis.

5. Phrenic Nerve Injury

The phrenic nerve innervates the diaphragm. The diaphragm is the principle muscle of respiration. That means it is the main muscle that allows you to breath.

Phrenic nerve injury can lead to paralysis has been noted with the transaxillary and supraclavicular approaches, which can lead to difficulty breathing.

The diaphragm performs most of the work, normal breathing with the help of the scalene muscles, the intercostal muscles of the muscles between your ribs, sternocleidomastoid muscles, and the trapezius muscles. If both diaphragms are paralyzed, these accessory muscles will be forced to do all the work of breathing by contracting intensely.

What is worse is that the scalene muscles would have already been surgically removed during the thoracic outlet syndrome surgery. So losing the function of your diaphragm and the function of the scalene muscles your breathing will be very difficult. The harder you have to breathe, the more you become fatigued.

6. Long Thoracic Nerve Injury/Dysfunction, Long thoracic nerve palsy

(winging scapula)

Long thoracic nerve palsy is a shoulder condition characterized by pain and loss of shoulder movement owing to damage or injury of the long thoracic nerve.

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

The long thoracic nerve that controls the serratus anterior muscle is very close to the ribs and collarbone. The serratus anterior muscle pulls the scapula forward around the thorax.

Injury to the long thoracic nerve causing paralysis or weakness of the serratus anterior muscle can be disabling. Patients with serratus palsy may present with pain, weakness, limitation of shoulder elevation, and scapular winging.

Due to its long, relatively superficial position close to the skin, the long thoracic nerve is susceptible to injury either through direct trauma, stretch, or it can be inadvertently cut during surgery (10) (38) (39).

Injuries to the nerve can result from carrying heavy bags over the shoulder for a prolonged time.

The roots from C5 and C6 pierce through the middle scalene and the surgeon is going to cut this muscle out. If he or she inadvertently causes traction damage or even cuts that nerve, it will cause a permanent paralysis and a winging of your shoulder blade (39–41).

7. Subclavian Artery Injury 1-2% (37)

The subclavian artery can be injured accidentally during surgery. Surgeons can repair this injury but it could require significantly longer lengths of stay and costs.

8. Subclavian Vein Injury 1-2% (37)

Injury to the subclavian vein or artery can occur during the surgery, because there is much manipulation with tools that occurs in this area. They pull these delicate arteries, nerves, and veins aside with metal tools tractioning them significantly. There is a potential for massive hemorrhage. If doctors aren’t capable of handling massive hemorrhage, they shouldn’t be doing surgery (38).

9. Postoperative Bleeding

Postoperative hemorrhage: Bleeding after a surgical procedure. After surgery, it is common to have some minor bleeding Sometimes patients bleed too much due to an injury to a blood vessel.

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, and other symptoms of shock and decreased blood pressure. If you have these signs or symptoms call 911 and the doctor immediately.

10. Hemorrhage or Bleeding

After surgeries, there can be postoperative bleeding (10). Injury to the subclavian vein or artery can occur during the surgery, because there is much manipulation with tools that occurs in this area.

They pull these delicate arteries, nerves, and veins aside with metal tools tractioning or stretching them significantly. There is a potential for massive hemorrhage. If doctors aren’t capable of handling massive hemorrhage, they shouldn’t be doing surgery (38).

11. Wound Hematoma (Associated With Excessive Anticoagulation)

A hematoma is like a bruise. It is a localized collection of blood outside the blood vessels. Some medicines such as aspirin or anticoagulants (blood thinners) can cause excessive bleeding after surgery. Patients receiving aspirin or low-dose heparin have a slightly higher risk of developing this 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 drained surgically, or take some time to disappear.

12. Residual Subclavian Vein Obstruction

This is a complication where some of the subclavian vein is still obstructed to a degree after surgery.

It is where the surgery did not remove all of the obstruction from the subclavian vein.

13. Early Postoperative Rethrombosis

The goal of thoracic outlet surgery is to restore blood flow in an artery or vein that has become compressed. Retrothrombosis is when the artery becomes either partial or complete occluded after the surgery has restored the blood flow within a short time after the surgery.

14. Late Postoperative Axillary Vein Obstruction

Late postoperative axillary vein obstruction is where the axillary vein becomes obstructed after surgery for thoracic outlet syndrome.

15. Late Postoperative Subclavian Vein Obstruction

Late postoperative subclavian vein obstruction is where the axillary vein becomes obstructed after surgery for thoracic outlet syndrome.

16. Rethrombosis

Retrothrombosis is when the artery becomes either partial or complete occluded after the surgery has restored the blood flow within a short time after the surgery.

17. Recurrent Symptoms

Recurrences means you still have the same major symptoms after the surgery or you feel worse. A recurrence is most likely due to these reasons:

1. Incomplete resection

2. Inadequate deep compression

3. Reattached scalenes

4. Scar tissue

5. Bony regeneration

If patient symptoms are severe, they might have 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 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 entrapment of the brachial plexus because of these adhesions. This will all depend on your after-surgery rehab program, however, even with the best rehab program, some patients just develop a large amount of scar tissue in an area of the surgery. So, when they take everything out, there is less to compress the neurovascular bundle.

You’d think when they remove the scalene muscles and the ribs, that that would be enough, but it isn’t. They only surgically removed three muscles when you now know that there are 10 muscles that compress the thoracic outlet.

Who is the best surgeon for TOS surgery?

This should be determined by long-term success rates. If you are considering surgery, some say its better to go to a teaching hospital.

A patient recently contacted me after his TOS symptoms returned following surgery. Before he made his trip to Chicago for treatment I asked him to send me a copy of his surgeons 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 do the surgery. Residents under the attending physicians guidance performed most of the surgery he had. When you have surgery at a teaching hospital with a residency program, residents are going to be involved with your surgery. While attending surgeons are required to supervise, residents are learning how to perform surgery by doing some of your surgery – that’s how the system works.

All residents are closely supervised at each step of the way being permitted to do more of the operation as they have demonstrated competency in a particular task. By the time they have completed their residency – which is five to ten years – they are capable of performing an entire procedure without an attending physician supervising.

All patients should be well-informed before making any major health care decisions like neck surgery. If they haven’t notified you, you should be proactive and ask questions to your chosen surgeon 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?
• Which parts of the surgery will you be performing?
• What are the possible complications?

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 team because they trained them.

Also, you should ask the hospital what the statistics are for the success of its thoracic outlet surgeries.

Some hospitals, performing a large volume of thoracic outlet syndrome surgeries, do short- and long-range outcome studies and publish them. Many of these studies are easily found by going to the National Institutes of Health, US National Library of Medicine, www.pubmed.gov or www.ncbi.nlm.nih.gov/pubmed/ and doing a search for thoracic outlet syndrome surgery outcomes.

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

It would be worth it to spend a few hundred dollars pulling studies to find the best team to do your surgery. You could also do a phone consultation with me to discuss your options. I’m here to help you.

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

You have to be nervous just prior to your consultation with a neurosurgeon. You are possibly facing neck surgery. 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 improved).

Good Result Good was defined as significant reduction in most symptoms with some symptoms remaining (60–90 percent improved).

Fair Result Fair was defined as relief or reduction in some symptoms with persistence of some major symptoms (20–60 percent improved).

Poor Result Poor or failed indicated not enough improvement to have made the operation worthwhile or symptoms were worse (<20 percent improved) (27).

You are about to see the surgeon to see if surgery 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 surgery with thoracic outlet syndrome.”

You are somewhat relieved, right? Not so fast. What does “success” 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. 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 in some symptoms with persistence of some major symptoms?”

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 did that determined the success of thoracic outlet surgery there was only one study that considered it a success only if the patient was pain free after the 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.”

Not one of these studies documented those patient’s success with this rating system or referenced those patients who were worse after conservative care or surgery.

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

This study found that patients undergoing surgery had missed more work time than those undergoing conservative management. 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 went back to work (45).

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

• 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 to worse 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.

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

Successful Surgery — Excellent was defined as relief of all symptoms (90–100 percent improved).

— Good was defined as significant reduction in most symptoms with some symptoms remaining (60–90 percent improved).

Failed Surgery — 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.

What are the long-term outcomes of surgery for thoracic outlet syndrome?

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

What is considered a successful surgery will surprise you and short-term success doesn’t last. The numbers of patients who fall back into pain after surgery are quite substantial, and this is a trend that happens in every study (47).

One study reported the results of surgery for thoracic outlet syndrome 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. However, after 18 months, the success rate fell to 46.9 percent.

Eighty of those whose first surgery was a failure were talked into a second 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 a success?

Their conclusion was that there must be a minimum of an 18-month follow-up on patients and standardized definition of the outcomes necessary to determine the true effectiveness and outcome of operative treatment of neurologic thoracic outlet syndrome.

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

So, if you see a post from your friend on the thoracic outlet syndrome awareness Facebook group or the Neurotalk forum excited about being pain free a few weeks after surgery, just wait and see if she feels the same way in a year or so.

Do surgeons think that you should be completely pain free after the 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. 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 TOS.

Exactly 27 percent were still pain free. More than 70 percent still had recurring pain or, worse yet, they say they would do the surgery again (50).

Would you be able to live in chronic pain, or would you seek a second surgery?

Recurrent symptoms develop in 15–20 percent of patients undergoing either first rib resection or scalenectomy 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 surgery for thoracic outlet syndrome, and it failed to give you relief, the choice of having a second surgery can be a tough one.

What government studies have been done to determine the success of TOS surgery?

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 injury.

The study determined that patients with thoracic outlet syndrome caused by trauma 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 work disability. 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 the pain or require 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 TOS 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. By the time patients get to me, they have oftentimes had TOS for several years, have been misdiagnosed several times, have had a few surgeries they did not need, and I was their last resort before surgery.

So I’m used to treating patients who have had TOS 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 complaints.

Workers with TOS who received surgery had substantially (50 percent) greater medical costs, were more than three times as likely to be work disabled 1.8 years following TOS diagnosis, and were more than four times as likely to be work disabled 2.8 years after TOS diagnosis than workers with TOS 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 surgery with thoracic outlet syndrome (50).

Outcomes of surgery for neurogenic thoracic outlet syndrome (NTOS) in workers’ compensation are poor in a majority of patients, partly due to nonspecificity of diagnosis.

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

The diagnosis and treatment of neurogenic thoracic outlet syndrome is highly controversial and associated with surgical interventions based on no clear evidence of presence of true thoracic outlet syndrome.

Considering the poor outcomes reported from the surgical management of neurogenic thoracic outlet syndrome in most workers’ compensation cases, this guideline requires objective evidence of brachial plexus disorder including abnormal electrodiagnostic tests.

After surgery, 20 percent of patients experienced a new adverse event, primarily related to new neurological complaints of lung pathology, the most serious of which is phrenic nerve dysfunction.

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

How soon before you can return to work?

A study of the outcomes of surgery done by the Department of Surgery of University of Michigan Hospitals found that patients return to work about 10 months after surgery. The study reported that 86 percent of patients were moderately to highly satisfied but only 55 percent of the patients had returned to full duty. Still 45 percent did not return to full duty, so as long as they did not have to work, they were ok with the surgery. If they had to return to work, they would have to work through the pain. So how do you do that? Of those patients, 9 percent were on narcotics and 30 percent were still taking NSAIDS.

After 47 months, only 65 percent of those patients reported improved symptoms. While 35 percent of patients remained on medication, 18 percent of patients were disabled (52). The answer is that there is no guarantee when you can go back to work or if you will ever work again.

So, what is the percentage chance that I could become reliant on opiates to cope with the pain after surgery? For many patients who have thoracic outlet surgery, their only hope of being pain free after surgery is with narcotics. In a survey of patients more than 100 months after surgery for TOS, 27.3 percent of them required continued postoperative narcotic analgesics (53).

What success did surgery for TOS have in getting patients off dangerous opiate painkillers?

One study compared how many patients could cope with pain without opiates before and after surgery or how many patients were able to get off opiates because of the surgery (54).

— 85 (55.2 percent) did not require opiates for TOS symptoms before the surgery.

— 69 (44.8 percent) needed opiates to cope with TOS before surgery. By three months after TOS surgery, your incisions should have healed and you should now be off opiate pain medication moving to an over-the-counter anti-inflammatory.

Three months after surgery these were the results:

— 53 (34.2 percent) did not require opiates for TOS symptoms after surgery.

— 101 (65.6 percent) needed opiates to cope with TOS symptoms after surgery.

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

So, the result of the surgery was that more patients who did not need opiates now needed opiates and the patients who were taking opiates needed stronger opiate dosages.

Six months after the surgery, here are the results:

— 81 (52.6 percent) did not require opiates for TOS symptoms after surgery.

— 73 (47.2 percent) needed opiates to cope with TOS symptoms after surgery.

So, after 154 patients endured surgery for thoracic outlet syndrome, only 4 patients got off opiates in six months. The other 73 needed opiate painkillers to cope with the pain. And 73 (47.2 percent) of the patients were still using moderate to strong opiate medications six months after surgery. Also, twice as many patients were taking strong opiates six months after the surgery than before the surgery (54).

If you start taking opiates right after surgery, what is the chance you can become reliant on the long-term use of opiates or become addicted to opiates?

An article published in Newsweek in March 2017, titled “CDC Study Finds Opioid Dependency Begins within a Few Days of Initial Use,” the question was asked, “At what point does the use of painkillers move from medical care to addiction?” (55).

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

The most likely patients to fall into long- term use were the ones given a one week- long prescription. More than 13.5 percent were still using the opiates a year later, if they took them for more than a week. And 30 percent became addicted, if they took them for more than a month (56).

So, it’s fair to say that the pain from the surgery for thoracic outlet syndrome can lead to an opiate addiction. Is there a way to avoid taking dangerous opiate drugs?

There aren’t many options left after surgery has failed to relieve your pain. We just mentioned the option of painkillers to ease pain. The problem with this approach is that eventually you need more drugs to ease the pain, leading to increasing dosages, which puts you at risk for overdose and death.

Doctors who have patients with failed spine surgeries can surgically implant a spinal cord stimulator (SCS) unit into your body. They implant the remote-controlled muscle stimulator gadget in your body and run wires through your spinal canal to attach to your spinal cord.

The transcutaneous electrical nerve stimulation (TENS) unit delivers electrical impulses to the spinal cord. The stimulation interrupts the feeling of pain, substituting a sensation called paresthesia.

You get a remote device to carry around with you to increase or decrease the stimulation through the TENS unit.

Doctors say it might reduce pain a little, so you don’t have to take as many drugs in the short term, although dosages will increase as you develop a tolerance for the medication. This will send you down the dangerous painkiller road, littered with the overdose cases we spoke of earlier.

One large study found that 38 percent of the volunteers had problems with the device. More than 22 percent said the leads, attached to the spinal cord, moved. In almost 10 percent of the volunteers, there was lead connection failure. In 6 percent of the cases, there was lead breakage (56).

About 4 percent got infections after the surgery, which increased to 9 percent for diabetic patients.

Failed back surgery syndrome accounted for 82 percent of the cases (57).

Have you ever experienced paresthesia? It’s called pins and needles. So, do you trade the severe pain for pins and needles? Have you ever tried to sleep with pins and needles?

If you have been recommended to have surgery for thoracic outlet syndrome, please feel free to contact me for a second opinion. Where did I get all this information? I got the results of these studies from the National Institutes of Health online database called PubMed. These outcomes I quoted came straight from the studies conducted and authored by the surgeons themselves. I know they don’t paint an optimistic view of what your life could be like after thoracic outlet syndrome surgery.

What did you expect? A doctor would cut bones out of your neck and you would be pain free? Here is a list of logical reasons why surgery will not take away your pain.

Why surgically removing two scalene muscles and the first rib cannot completely decompress the interscalene triangle.

1. The posterior scalene muscle attaches to the second rib. This muscle is also in as much of a spasm as the anterior and middle scalene, but they don’t remove it. The second rib attaches to the spine only one inch from the attachment of the first rib. When your vertebra bend to the side, they all bend together. So, if the first rib is elevated up into the outlet the second rib is also elevated up into the outlet.
2. When the subclavius muscle is in a spasm, it also lifts the first rib and pulls the collar bone down into the outlet at the same time. They never surgically resect this muscle.
3. After surgically resecting these muscles and the first rib, scar tissue forms as part of the healing process. This scar tissue constricts muscles and joints and can cause decreased pain- free range of motion over time.
4. The scalene muscles are extremely important in achieving a delicate balance of tension for the head to balance perpendicular to the downward pull of gravity. Removing these muscles makes it impossible for you to balance the tension around the head and neck area ever again.
5. The scalene muscles help to protect the neck from injuries. If you are in a car that gets hit from the side (T-boned), your risk for severe neck injury is much greater and most likely, the injuries will be more severe.
6. MOST IMPORTANTLY! If the first rib floor is lifted up into the outlet/tunnel by the scalenes then surgically removing the first rib only opens a little space on the floor of the outlet. If the roof of the thoracic outlet/tunnel or the shoulder girdle is still being pulled down by muscles into the thoracic outlet/tunnel causing compression you will most likely still have thoracic outlet syndrome after the rib resection surgery. In my experience working with TOS patients, every muscle that compresses the outlet is contracted. Cutting out muscles just because your physical therapist didn’t do the deep tissue work, didn’t treat all the muscles or did not treat the muscles long enough is no reason to give up and have the muscles and the rib they attach to surgically removed from your body. Do you do this when you have a chronic shoulder, back or leg spasm? Do you cut the muscles out in those areas too? No.

A talented chiropractor with a good first rib adjustment technique can easily adjust your first rib down out of the outlet/tunnel. If you are hesitant to go to a chiropractor or have a bias against them, is it that important to you that you leave the rib elevated compressing your blood vessels and nerves so you have to have neck surgery to take it out. Lets see… some adjustments to move the rib down or neck surgery to completely remove it and the supportive muscles in the neck too. Where is the logic in that?

It is estimated that chiropractors treat over 27 million Americans annually, with a chiropractic adjustment being performed around 1 million times every business day in the US. It takes a special skill set to give a good first rib adjustment. You may have to go to a few chiropractors to find a good one that can really drive that rib down. You may want to start by going to the Foundation for Chiropractic Progress to find a chiropractor in your area.

www.f4cp.com/findadoctor

Why only surgically removing the pectoralis minor cannot completely costoclavicular space and the subpectoral space.

1. The pectoralis minor muscle is not the only muscle that drags the shoulder girdle into the costoclavicular and subpectoral space. The biceps short head and the coracobrachialis muscles also attach directly to the same coracoid process as the pectoralis minor. So surgical removal of only the pectoralis minor does not provide for a complete decompression of the costoclavicular and subpectoral spaces following surgery.
2. The subclavius muscle also drags the shoulder girdle down into the thoracic outlet. At the same time, the swelling of this muscle narrows the costoclavicular space. The surgical resection is not considered with the current strategy to decompress the thoracic outlet.
3. The latissimus dorsi and the lower trapezius depress the scapula from the back, however, these muscles are not treated or resected with the current approach thoracic outlet surgery decompression.
4. There are ten muscles that directly contribute to the compression of the interscalene triangle, the costoclavicular space, and the subpectoral space, yet only three are considered for surgical resection. Therefore, after surgery to remove these three muscles there are still seven more muscles that can compress the thoracic outlet.
5. Because these muscles have attachment on other ribs, the shoulder, and the neck, the amount of imbalance creates a significant lack of coordination within the nervous system.

It could take years for the body to relearn all the coordinated movements without these important three muscles providing stability to the region.

If you get surgery for thoracic outlet syndrome and are still in pain, this is expected. The surgical strategy for treating thoracic outlet syndrome is not supposed to be able to get you completely pain free. If you are completely pain free after surgery you are in the rare 10-15 %.

I have to give the surgeons a huge amount of credit if they can even get a few patients out of pain with surgery. Surgeons who do Surgery for thoracic outlet syndrome are some of the most intelligent and seasoned surgeons in the hospital. Also only a few hospitals in a major city or state have qualified surgeons who can perform this surgery.

If you have surgery for thoracic outlet syndrome and you do not have a blood clot or embolism, my opinion surgery is NOT necessary. What is necessary is that your therapist or chiropractor read this book and follow my recommendations.

Remember, once you surgically remove these muscles and bones with neck surgery, you cannot put the muscles and ribs back in your body. You will be stuck in pain or contemplating another surgery that may or may not make you better.

Now are you willing to give the nonsurgical human spring approach a look?

Let’s spring into Chapter 13 where you can learn about a more logical human spring approach to hopefully, end the suffering.