Frequently Asked Questions

Yes. In fact, most people who have TOS do not have cervical ribs. Around less than 10% of TOS patients have cervical ribs. Most people with cervical ribs do not know they have them and do not experience any issues from them. ATOS is almost always associated with a cervical rib or other bony abnormality, but most people who have cervical ribs do not have ATOS.

Yes, particularly NTOS. It’s not uncommon to have it on both sides particularly if the predisposing anatomical anomalies are present on both sides and if the predisposing injury or task affects both sides. For example, a whiplash injury affects the muscles on both sides of the neck.

TOS specialists are usually vascular surgeons and occasionally cardiothoracic surgeons. However, most vascular surgeons and cardiothoracic surgeons DO NOT specialize in TOS, so it needs to be one who specializes in TOS. A preliminary diagnosis most commonly comes from orthopedic surgeons, peripheral nerve surgeons, neurologists, ER doctors or even non-specialist vascular surgeons, but once the diagnosis is suspected, a referral to a TOS specialist should be made.

Typically, no. However, there usually needs to be at least a high suspicion of it from some sort of physician. The definitive diagnosis should only be made by the TOS specialist.

No. TOS surgery should never be done on both sides at the same time. There is a low but known risk of phrenic nerve injury with this surgery. There is a phrenic nerve on each side that controls the diaphragm on each side. The diaphragm is the major muscle that helps with breathing. If the phrenic nerve gets damaged, the diaphragm will not function properly, and it can affect the ability to breathe. If only one side has a dysfunctional diaphragm, you can still breathe as the diaphragm on the other side can overcompensate. However, if both phrenic nerves are damaged, then it could mean losing the ability to breathe and needing to be put on a ventilator. So, this is the main reason why TOS surgery should never be done on both sides at once. However, pec minor release surgery can be performed on both sides at once as it does not carry the risk of phrenic nerve damage.

Scar tissue is a normal response by the body to heal anything that is injured or damaged. Anything that causes inflammation and damage within the area of the thoracic outlet or to the structures within the outlet can cause scar tissue. It can be an injury such as a car accident or a fall or it could be from anatomical anomalies not allowing enough space for the structures within the thoracic outlet such that every time a certain movement happens, the structures keep getting compressed over and over again resulting in damage to them which results in scar tissue.

The anterior and/or middle scalene muscles are the neck muscles that are removed or severed during surgery. Removal of the scalenes doesn’t tend to have a big impact on weakness or instability of the neck. They’re not really a big part of the main stability or strength part of the neck. One of their main functions is to elevate the first rib during inspiration and obviously if the rib is gone, that function is no longer needed. They do assist with lateral side bending of the neck along with about 9 other muscles so there is plenty of backup for that. They also assist with bringing your head down to your chest but there are also other muscles involved with that action as well. There are usually a fair number of other muscles that participate in these functions so the extra work gets spread around quite a bit which makes the change less noticeable. That said, some people do end up having SCM tightness or spasm after surgery because the SCM is involved in almost every neck movement, and it can get irritated due to its increased workload. The potential exception to this is for patients who have Ehlers-Danlos Syndrome or other connective tissue disorders. Some, but not all, of these patients can end up with craniocervical instability following scalene removal or detachment.

Yes. The most common reasons for a recurrence are (1) complete decompression not achieved during surgery and (2) scar tissue formation due to additional injury. More information about recurrence can be found on the treatment pages of this website.

Some experts say yes, and some say not really. If the part of the rib that is being removed is completely and fully removed, it should not happen. However, it is suspected that what has been described as regrowth is actually a calcification and dense fibrous tissue response to rib periosteum left behind after removal. So, essentially a result of incomplete rib resection.

Depending on surgeon protocol, it is either for the purpose of preventing, monitoring for or treating a lymph system duct leak known as a chyle leak. The lymph system runs directly through the surgical field and can sometimes get disturbed during surgery resulting in a leak of lymph fluid. The lymph system absorbs fat from the digestive system and transports fat to the blood circulation. Therefore, the more fat that is eaten, the more drainage is created by the lymph system. So, the less fat that is taken in, the less drainage there will be running through the lymph system. With less fluid, the leak has a better chance of sealing off on its own and causing less drainage to leak into the surgical site and/or chest cavity.

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None. Rarely, it will show up on an EMG or nerve conduction study. The scalene muscle block injection is probably the closest thing to a test that indicates NTOS. NTOS is mainly a clinical diagnosis of exclusion. For more detailed information for diagnosing NTOS, click here.

Yes. A vascular surgeon who specializes in TOS treats all forms of TOS including NTOS.

Yes. Although numbness and tingling are very common symptoms of NTOS, it is not present in every patient and is not required for a diagnosis.

Yes. The majority of people who have NTOS have a normal EMG. It is mainly ordered to rule out other conditions that mimic TOS. For more detailed information for diagnosing NTOS, click here.

Yes. A positive muscle block response is not required for diagnosis. There are several reasons why someone with NTOS might not respond to the block. For more detailed information for diagnosing NTOS, click here.

Yes. A positive response to Botox is not required for diagnosis. Not everyone responds to Botox. It is also not widely used as a diagnostic tool. For more detailed information for diagnosing NTOS, click here.

This can be quite difficult as many symptoms of both conditions overlap, but there are a few distinguishing elements outlined below. A highly experienced TOS specialist with a highly experienced spine surgeon should be helpful in making the determination. Cervical radiculopathy can often be seen on an EMG. Also, pain from it can sometimes be relieved with arm elevation. The pain pattern tends to be more consistent than TOS pain. Often the pain pattern from radiculopathy matches up with the known pain patterns/locations associated to specific levels where disc bulges might be seen on imaging. Restrictions in neck mobility and spasticity can indicate cervical spine disease. Pain with palpation of the back of the cervical spine is also indicative of spinal disease. Cervical epidural or nerve root injections can also be done to help with diagnostics as whether and how much a patient gets relief from the injection can help to rule cervical spine issues in or out. People with Neurogenic TOS usually have an extreme tenderness in the area of the scalene triangle above the collarbone or in the area of the pec minor where it attaches to the front of the shoulder. Pressing on these tender areas can also reproduce nerve symptoms in the shoulder, arm or down into the hand. Symptoms are often triggered by arm activity particularly overhead or with the arm dangling down such as when walking. Symptoms can usually also be reproduced by turning the head toward the shoulder of the affected side or by side bending the head down toward the shoulder of the unaffected side. Occipital headaches at the base of the skull are the most common type of headache associated with TOS. A scalene muscle block injection can also be done to help with diagnostics to determine whether symptoms are TOS related. These are some of the main differences between the two conditions but obviously everyone presents differently and may not fit into these molds, and it is possible to have both cervical radiculopathy and NTOS.

Most surgeons will say that a positive muscle block response is a good indicator that a patient will be a good candidate for surgery. Some surgeons will say that the opposite is also true which is that a patient with a negative muscle block response is not a good candidate for surgery. In the past, it was more widely thought by the experts that scalene muscle blocks were a decent predictor of surgical success. However, more recently, some experts are backing away from that thought process, and there have even been some published studies that showed that the difference in surgical success between those who had a positive block response and those who had a negative block response is statistically insignificant.

Success of NTOS surgery is a very subjective definition. Many factors affect surgical success such as age, severity of compression, length of time of compression, what is done during surgery, and the experience of the surgeon. Success rates can also be dependent on the individual surgeons. With a high volume highly experienced TOS surgeon, somewhere around 90% of patients obtain significant relief.

Yes, but not for everyone. There are people who have been healed completely but due to the nature of NTOS and the fact that most people don’t get diagnosed very quickly, many people still have some lingering symptoms or issues that they must continue to manage even after surgery. There are many factors that impact this, and no two cases are alike. For most who are in significant pain prior to surgery, they describe it as being given their life back even if that means that they’re not 100% pain free or have some lingering symptoms.

This has been a debate that has gone on for decades related to TOS. Studies published during that time have essentially shown very similar success rates with the two approaches. It appears that with highly experienced TOS surgeons using the approach of their preference, the results are excellent. In order to come to an ultimate conclusion, a prospective, randomized, clinical trial would need to be done to compare the approaches. However, that doesn’t mean that experts don’t have their own opinions as to the pros and cons of each approach. For more detailed information as to the pros and cons of each approach, click here.

As far as ultimate outcome is concerned, the answer is that it likely does not matter. Surgeons who perform them separately would argue that it is not always needed thus why do a surgery that might not be necessary. Surgeons who regularly perform them together would argue that a majority of patients end up needing the surgery, so why not get it done in a single procedure and not subject the patient to anesthesia more than once. The consensus among patients seems to be that they prefer to have all the procedures done in a single surgery versus needing to have two separate surgeries.

Almost all surgeons order some level of PT after surgery. Protocols vary among surgeons. Some will have patients do very little except a few minor stretches at home on their own. Many will have a regimen for the patient to participate in under the guidance of a physical therapist. How long or how much PT is required depends on the patient and their condition after surgery. A physical therapist knowledgeable in TOS or nerve surgery recovery in addition to communication with the surgeon is paramount to avoid injury from PT post-surgery.

For thrombotic VTOS involving a blood clot, yes surgery is necessary. The blood clot is caused by external compression of the vein by the first rib and other structures, so the only way to stop the compression is to remove the offending structures. Unless the compression is removed, the vein continues to sustain damage and the risk of further clots remains.

This depends on the surgeon and surgical approach. With a high volume highly experienced TOS surgeon, success rates are in the 95-99% range.

Yes. The majority of patients having surgery for VTOS do get back to all their normal pre-surgery activities especially in the hands of a highly experienced TOS surgeon.

All three surgical approaches have very high success rates. However, there are definitely pros and cons to the approaches as some of the success rates occur with the use of a combination of surgery and post-op balloon angioplasty as opposed to just surgery alone. For more detailed information as to the pros and cons of each approach, click here.

Most surgeons order at least a brief period of PT after surgery to regain arm strength and range of motion.

No. ATOS diagnosis requires a clot, aneurysm, or other damage to the artery. Therefore, this finding alone does not suffice for a diagnosis of ATOS. For more detailed information for diagnosing ATOS, click here.

Yes. Surgery is necessary to restore blood flow and repair the artery. The compression of the artery is almost always as a result of a cervical rib or other bony abnormality, and thus the only way to stop the compression is for those bony structures to be removed. Without surgery, the artery will continue to sustain damage and continue to clot.

This is a bit difficult to quantify due to the relatively low number of surgeries performed for this condition compared to the other types of TOS. Success is highly dependent on quick diagnosis and prompt appropriate treatment. In the hands of high volume highly experienced TOS surgeons, success is around 90%.

Yes, but again this is highly dependent on quick diagnosis and prompt appropriate treatment. In the setting of clots that embolize to multiple arteries in the arm which are not treated promptly or appropriately, long term symptoms can remain. This is also dependent on whether NTOS coexists and to what extent since adding nerves to the mix can change the dynamic as to whether there are lasting symptoms.

All three surgical approaches have high success rates. However, there are definitely pros and cons to the approaches. For more detailed information as to the pros and cons of each approach, click here.

Most surgeons order at least a brief period of PT after surgery to regain arm strength and range of motion. This is also dependent on whether NTOS coexists as surgery on the nerves can significantly impact the post-op functionality of the patient.