Thanks to the new 12hour edit rule I'll make this one a new post....

So I went out to denver about 2.5 weeks ago. I hopped on a plane monday morning, had some pretty stressful travel (way too long lines, delayed planes and the like) that I wasn't prepared for, and arrived at Dr Brantigan's office late and in somewhat more ruffled shape than I would have liked.... They were fortunately having a light day and were able to accomodate me anyhow, which was cool.

I first met the NP who was nice (forgot her name?) but didn't do much. Dr Brantigan had supposedly read all my records before I came, but in going over my history i pointed out a few things to him that he had missed. First and foremost was Dr Jordan's ultrasound report of my right side where he clearly saw a fibrous band and an extra artery (or vein? can't remember...) because it was done with my right scalene block and Dr Brantigan had glossed over the report because he "didn't really think blocks were all that reliable"

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note: I have since come to some understanding of the difference between the Blocks that Dr Jordan and Dr Ahn do as compared to other docs. Dr Sanders, for instance, sticks you with the medicine and then asks if you feel better...Dr Jordan and Ahn use EMG monitoring to make sure the medicine goes exactly where they want it and and make recordings during the block. I haven't got it all figured out but I intend to ask for another explanation the next time I see Dr. Jordan)
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Actually, Dr Brantigan pretty much didn't like anyone's techniques for diagnosing TOS, except perhaps the SF based group doing the MRI/MRA with contrast. HE seems to rely extremely heavily on his own physical examinations and on the spiral CT scan. Doesn't like the scalene block, doesn't like Nerve Conductions Studies (like the MAC study Dr Sanders is doing), said SSEP was useless (I guess he didn't notice it was used as a rule out technique), and didn't like Dr Collins's MRI/MRA (said they were concentrating on "different things" but didn't elaborate on what those were).

He does have a very logical approach , and gave me some papers to read (the link was my favorite, and I can't find any of the others full text anywhere) that explained it. To summarize: everyone with TOS has some sort of anatomical anomoly and to fix the TOS you must locate and fix the anomoly. His papers describe 10 particular types of lower plexus anatomical varieties and another 6 or so types of upper plexus varieties. The lower plexus were things like extra ribs, cervical fibrous bands, partial cervical ribs that reduce to fibrous bands, and on and on. He was very specific as to location and type of these things which is why so many. He stated that he concentrated on bony structures.

He gave me a very thorough physical examination, but I generally don't reproduce symptoms well in an office setting. usually it is more delayed or while working on the computer, whatever. He was generally unimpressed with me there. I Explained to him the parts about being on pain meds all the time and not being able to sit in a chair to work, the pain in my back, etc and he took that all in thoughtfully.

At the end of our appt he indicated that I seemed to have a lower plexus injury on both sides and he would likely be willing to operate, but wanted to see the Spiral CT results, even though they don't usually show things like fibrous bands. So I went to get the spiral CT, and he said he'd call me in a few days. .

It then took him 2 weeks to get back to me. I guess my CT results got sent into cyberspace instead of the radiologist. After all this waiting and his ripping on everyone else's diagnostic techniques.....The CT came back completely normal.


By the time I talked to him about the results, I had also read the papers he gave me. Now I had always been confused about why my left and right sides felt so different but had the same "syndrome." I stumbled across a paragraph in the linked paper that was precisely a description of the symptoms I do get on the left and I don't get on the right. It went on to designate them as upper plexus symptoms and then to describe the rest of the normal TOS symptoms as lower plexus symptoms.

He further went on to suggest in this paper that if one had upper plexus symptoms that besdies a txiallary rib resection, he would do a supraclavicular scalenectomy at the same time.

When I talked to him about this part in his paper he said that he could revisit my upper plexus symptoms when I came back for surgery, but that he had been "unimpressed" in his physical exam and history that I had upper plexus involvement. (those aprticualr symptopms are intermittent adn I hadn't mentioned them becasue I forgot...but was having them the whole way home because of aggravation from all the testing) However, that IS the surgical course he takes for one with upper plexus syptoms.

In the end, I feel like I got some good information from him. Understanding the difference between upper and lower symptoms has been key in my decision making process. I guess If I had looked harder I might have found the info without going all the way to Denver, but in any case I have it now.

He also wrote a very nice, very detailed report including his exam notes, the history he had taken, and many thoughts and impressions. He faxed it to me the day I got my CT results.

Maybe if I lived in Denver I'd have surgery with him, but he wanted me to stay two weeks for surgery, and there is just no way I can stand to be away from my kiddos that long, so I didn't think it was likely i would choose him.