fyi- this group of doctors up in Seattle seem to think the pec minor is often the cause of recurrence.

Stay optimistic and please follow-through on the pec minor testing. Let us know how it goes. best wishes -

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[Recurrent neurogenic thoracic outlet syndrome
Esteban Ambrad-Chalela, M.D., George I. Thomas, M.D., Kaj H. Johansen, M.D., Ph.D.*
Vascular Institute of the Northwest, 1600 E. Jefferson St., No. 101, Seattle, WA 98122, USA
Presented at the Annual Meeting of the North Pacific Surgical Association, Seattle, WA, November 8, 2002


Abstract

Background: Although 90% of patients with neurogenic thoracic outlet syndrome (NTOS) experience “excellent” or “good” results after
thoracic outlet decompression, recurrent symptoms may develop in certain patients.

Methods: This is a retrospective review of patients with NTOS who developed recurrent symptoms of upper extremity/shoulder/neck pain,
weakness and limitation of motion at least 3 months after initial relief of symptoms by surgical decompression. Diagnostic procedures and
outcomes of reoperative surgery were assessed.

Results: Among almost 500 patients undergoing initial successful thoracic outlet decompression for symptoms of NTOS during the last
decade, 17 redeveloped classic NTOS symptoms (3 of them bilaterally) at intervals from 3 to 80 months (mean 18 months) after the initial
operative procedure. Ultimate diagnoses included incomplete first-rib resection (n=1), compression of the brachial plexus by an ectopic
band (n=1), persistent brachial plexus compression by an intact first (n=2) or second (n=1) rib, brachial plexus compression by the
pectoralis minor tendon (n=13) and adherent residual scalene muscle (n=14). Anterior scalene muscle block was positive in 9 patients
later found to have recurrent symptoms from adherent residual scalene muscle. Among these 20 cases of osseous or musculotendinous
causes of recurrent NTOS, all had “excellent” or “good” results from repeat surgery to eliminate the underlying structural problem (removal
of intact or residual rib, pectoralis minor tenotomy, brachial plexus neurolysis, or a combination of these).

Conclusions: Complete excision of cervical or first ribs and subtotal excision (instead of simple division) of the scalene muscles will
decrease the incidence of recurrent NTOS. Pectoralis minor tenotomy should be considered part of complete thoracic outlet decompression.Anterior scalene muscle block accurately predicts outcome of reoperation for certain types of recurrent NTOS.]
http://www.ncbi.nlm.nih.gov/pubmed/15041500