Question 1

Can you have TOS without cervical ribs?

Accepted Answer

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.

Question 2

Can you get TOS on both sides?

Accepted Answer

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.

Question 3

What type of doctor diagnoses and treats TOS?

Accepted Answer

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.

Question 4

Do you have to have a diagnosis before seeing a TOS specialist?

Accepted Answer

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.

Question 5

Can you have TOS surgery on both sides at the same time?

Accepted Answer

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.

Question 6

How can someone have scar tissue if they haven’t had surgery yet?

Accepted Answer

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.

Question 7

How does the head stay up if muscles are removed from the neck during surgery?

Accepted Answer

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.

Question 8

Can TOS come back after surgery?

Accepted Answer

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.

Question 9

Can the rib regrow after it is surgically removed?

Accepted Answer

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.

Question 10

Why do some surgeons put patients on a low-fat diet after surgery?

Accepted Answer

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.

Question 11

What can I do to help spread awareness of TOS?

Accepted Answer

Click here to go to our Get Involved page where you will find different ways that you can help out!

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