for me, the next step has been to see the neurologist and have another round of scalene blocks to see if more surgery might be useful. Dr Ahn will perform a more complete scalenectomy supraclavicularly if the txiallery rib resection isn't enough.

if that still doesn't work, he also offers a pec minor tenotomy, now.

I am having more surgery, and after that i expect i might still need botox injections to really function well...

If you are still having multiple problems, i would try to get back to a knowledgeable neuro who might help dx any other issues. I would ALSO go get a full rheumy work up, and any other thing you can think of that might be having an effect. Also, get yourself into some good massage therapy or physical therapy with someone who can work on soemthing like feldenkrais or alexander technique who is used to workign with people in chronic pain. Some gentle assitance gaining range of motion or helping to stand up straighter can make a lot of difference.

wish i had somethign better to tell you, that is just what i would do.