You're welcome. I've noticed the same thing, but I was so grateful for this forum and the people on it that I promised myself I would keep checking back, even if I improved so much I'd rather forget the words "thoracic outlet syndrome" ever applied to me. This forum gave me so much information and hope when I needed it - I can't pay it back, but if I can help someone else, now or in the future, maybe I can pay it forward. :-)

So, on to your questions! None of the doctors I saw ever suggested Botox, or really even mentioned it, other than that it was listed in a handout. From what I understand, it's a pretty hit-or-miss thing with patient response - your experience with it is not unusual.

By the time I made it to Dr. Pearl, I had already had every test in the book - MRI, CT, contrast MRI, contrast CT, contrast CT with stress movements, vascular ultrasound with Doppler, trans-esophageal echocardiogram, multiple neurological assessments and multiple nerve blocks. I had a scalene block done about a week before I contacted Dr. Pearl that had given me enormous relief, and that's generally the "acid test" for whether or not surgery will help you. Based on a thorough review of my history and test results, he gave me a physical exam with some stress positions, an assessment of reflexes and nerve function in office and was satisfied that surgery was indeed needed.

When I contacted their office to make an appointment, they scheduled me the way they schedule their "long-distance" patients - the first appointment of the day with a surgery slot for the following day. That way any diagnostic tests Dr. P wants to run get done right after the appointment, so he can still make a decision that day. If it turns out surgery isn't indicated, they just cancel your surgery slot. All I had done there was pre-surgical bloodwork, ECG, chest x-ray and spirometer reading (since they collapse your lung for the surgery and want to know how you breathe prior to surgery so they can get you back to that point post-op), and they did all that the next morning before surgery.

It might be set up differently for someone who had NO prior testing, but I doubt most people end up contacting a TOS specialist if they haven't already been through a lot of them. ;-)

If your current vascular doctor is stymied, I would strongly suggest you make an appointment with an expert, preferably one that has been recommended by someone with personal experience with them (people on this forum are a good choice!). Even though no one here had posted about a personal experience with him, I went ahead and made the appointment with Dr. Pearl based on the information that he had studied under Dr. Urshel, who is highly recommended on this site and listed in the list at the top of the forum, and he was close enough to me geographically to take the chance - after all, if I hated him and wanted to go to someone else, I'd only wasted a day driving to Dallas and back. But after meeting him and talking with him, I felt confident proceeding with surgery with him, and I'm glad I went with my gut (and everyone on the sports-loving side of my family were glad I went with someone CC had confidence in; yeesh!). I absolutely think he should be added to the list on the forum, btw.

There are so many experts in cardiovascular surgery and neurosurgery where I live that I couldn't understand why everyone local that I saw was either ignorant, scared, or both about TOS surgery, but I've come to understand the complexities well enough to see why (finally). After dealing with all their worries and excuses, it was startling (and VERY reassuring) to me to have Dr. Pearl discuss it as though it were a very routine thing - but I guess when you do several of them every day, it is a routine thing.

And I would also encourage you to go with your instinct. I saw Dr. Sam Ahn before I saw Dr. P, and I know some people on this forum have had good experiences with him. Personally, I didn't like him, or the facility, so I kept looking, and I'm really glad I did. There may not be a plethora of TOS experts out there, but there are enough that you should be able to find one that you are comfortable with and have confidence in.