I’m almost at the end of my search. I had 2 very informative phone conversations with both Annest and Brantigan yesterday. Gelabert hasn’t gotten back to me, and I just don’t have the time to wait around at this point so I am taking him out of my options. Both Annest and Brantigan helped clarify the questions I was asking about removing vs cutting the scalene muscles. It helped confirm that with the transaxillary approach, you cannot remove the muscles completely, only cut and move them up. But with supraclavicular, you can remove them.

I will start with Brantigan. He said the only other test he would like to do with me is a “special” CT scan to help find out whether I have a fibrous band from my c-rib to first rib which he believes is the case and is more common than a c-rib alone causing compression. This CT scan has to be done in Denver with his radiologist who is apparently the only one who knows how to read it. He also explained more than any other surgeons my brachial plexus MRI results (showing generalized edema of the plexus) and said this radiologist can help with further explaining that as well. Scalene block is not useful to him, says it is impossible to carry out exactly how you want to.
For surgery:
-Transaxillary approach
-first and cervical rib resection, however he said he does NOT take out the entire rib, and leaves a small stump because otherwise there can be damage to the spinal cord
-disect out the anterior scalene muscle and part of the median muscle and cut and move them up IF it is only the upper trunk of my BP that is being compressed, but if it’s the lower trunk (my symptoms show it is or may be both but lower is worse), then he said he wouldn’t even have to cut the scalene muscles, and if its BOTH, then I would need a scalenectomy to remove them
-I asked why can’t you take them out? His response was that the reason scar tissue develops is because you take them out
-does 40-50 surgeries a year, 80% success rate for “routine” cases
-surgery 2 hours long, stay in Denver for 2 weeks physical therapy with their therapist and then take those instructions to my local therapist, 6 week recovery during which he said no vigorous exercises and then the second 6 weeks I would do more
-off from work 4 to 6 weeks depending on how I do
-he said he would do the other side within 2 to 3 days if I needed it that quick, said he is very selective about doing both sides within a week, but it all depends on how bad my left is at that point

So overall, I really really liked Brantigan. Very nice man, clearly very experienced. What I am not so sure about is the fact that he said he doesn’t remove the entire rib and also the specifics on the scalenectomy. I would obviously have to go out and see him to be properly evaluated, which I am now considering. He said I could either go out there to do the test and evaluation and then go back if I want to schedule surgery, or I can schedule a tentative surgery a couple days after my consult with him so I only have to make one trip.

Next is Annest Very friendly and kind. He mentioned doing a CT scan too (I think it’s the same one Brantigan mentioned), but he also wants me to do a MAC test for pec minor and a C8 NCV (nerve conduction velocity) test. He said he definitely thinks I am a surgical candidate and there is a “good likelihood” I would benefit from surgery but I don’t need to rush into it. But he thinks eventually I will need the surgery if I don’t do it now since my problem is anatomic (cause of the c-rib). In addition to explaining what my c-rib is doing, he said I also may have an aneurysm of my artery (?). He is the first to mention anything like this.
For surgery:
-Interestingly, he does either approach, said he would do transaxillary if the first rib needs to be removed, but if not, he would do supraclavicular, he said he really can’t tell me which he would do until he evaluates me in person
-I brought up the research I read about removing the rib reducing recurrence, he said Sanders is the one who wrote about that and now I recall the article I read was by him, he said they have learned that it is not always necessary and it depends on the rib’s appearance/shape
-he would remove the scalene muscles only by supraclavicular but first rib removal he would only do by transaxillary….so it seems like its either one or the other, or he even said he could do both but that would obviously leave me with 2 incisions, by transaxillary, he would loosen and disconnect the muscles but he said “they will grow back”
-seems like he is leaning toward supraclavicular because he thinks I have upper and lower trunk involvement and he could still take out the c-rib this way, but not the first rib
-he said he would do a pec minor tenetomy at the same time, if my MAC test is positive
-does 3-4 surgeries a week
-complication rate for surgery low especially with a c-rib
-said both approaches yield approx. 20% recurrence rate usually due to scar tissue
-Recovery “hurts like you’ve been kicked in the chest”, said I would be on getting narcotics through IV for 36 hours so hospital 2 nights or more, stay in Denver for 1 week
-can drive and begin PT in 1 week to 10 days, Range of motion over 3 weeks
-continue PT at home with his PT’s instructions (just like Brantigan)
-he also said he can do both sides within 4 days
-off work 4 to 6 weeks and probably a 3 day work week for a while if I go back after that

I told Annest that I had just spoken to Brantigan earlier and he said to make it easy for me, I can go ahead and schedule appointments with them both and tentative surgery, and he doesn’t mind if I cancel surgery with them to do it with Brantigan. He kept saying “this is about you” not us and I like how considerate he was. He said he was going to consult with Sanders about my case since he works very closely with him (who is still on vaca until Monday).

So…I have to make a decision now and I have narrowed it down to Urschel, Annest and Brantigan. It seems like it would make sense to go with Annest or Brantigan seeing as Denver is a bit closer to CA than Dallas and mainly because I can fly out there and in one trip, see them both, decide and do the surgery within the same week. But I did really like Urschel too. I have always been so indecisive! Any input/suggestions would be appreciated, this is getting tougher by the day!

Wow,great and through info. I was also impressed with Brantigans website. It looks like it may be worth a trip out there. I also like the amount of experience Sanders has and all the articles I have read by him.

Once you meet the Doctors in person, your decision will become clearer I believe.

I think you're right. But I don't want to make 2 trips if I don't have to since the traveling will just aggravate my symptoms. I am leaning toward Annest or Brantigan and will probably not decide until I go see them both with tentative surgery scheduled a couple days after my consults.

What approach was used for your anterior scalene muscle resection? I had a first rib resection but there is still quite a bit of tightness in the area, so I am looking to possibly had a second surgery to remove or divide.. Not sure what they do... The anterior scalene. Thanks in advance

Makenzie

PARBIE- I am very impressed by your detective work on going and researching these doctors. I live in NY and have spoken to Dr. Brantigan and that is who I want to see for my diagnosis and possible surgery. I think I have ATOS or VTOS. My health insurance will not cover any doctor outside of NY. THey are trying to convince me to see the doctors at NYU but I know they are not nearly as experienced as the Denver doctors. I am so upset about this because its my life and well being and I even switched health insurances thinking it would cover out of network and it doesnt. I do not know what to do! I dont understand how people do it when their insurance doesnt cover it. I am getting new insurance soon but I dont know if they offer out of network. I am not too familiar with health insurance plans. Have you met Dr.Brantigan yet? I wish I were as lucky as you and could go to any doctor. I am devastated and concerned about my health over this.

If your first rib was resected the anterior and middle scalene were clipped as well (along with anything else that attaches to the rib, like the subclavius). Full scalenectomy cannot be performed transaxillary and requires supraclavicular approach. Limoges' procedure was supraclavicular.

I'm sorry to hear that you are having so many issues with your insurance. Luckily, both Brantigan and Annest are in network providers under my insurance plan, as I learned regardless whether I met my max and deductible if I chose out of network I might end up with some unexpected costs later. I have been meaning to post an update. I have not yet seen either doctor and because of conflicting schedules for Brantigan and Annest, and because Brantigan said he couldn't operate until at least the second week of September, I chose to go with Annest and have everything booked for the last week of August including the tentative date for surgery. However, I thought it worthwhile to check my options and see if I could see Annest and Brantigan just for consults and testing earlier and then book a surgery a couple weeks later. I just found out today I can see them both the week of August 13 but Brantigan's schedule for surgery is still up in the air (since he is moving practices). I am so confused right now whether I should just stick with my first choice and go with Annest, make one trip, save time, energy, time off work and money by traveling once (TOSers, I would love some input on this!). Or just make 2 trips to see them both before deciding. What made you decide on Brantigan? Did you also speak with Annest? By the way, try looking into United Healthcare, Brantigan is covered by that insurance, it's the one I have.

I think you can't go wrong with either of them. They were the most mentioned TOS surgeons for years, now there are many more top surgeons in other locations being mentioned.

This is just my personal opinion of what I would do (actually, what I almost did). I would make 2 trips. I would need some time between consulting with the surgeons and surgery. I would need a week or two to digest everything, ask additional questions, and mentally prepare myself for surgery. A trip to Denver is a short direct flight for me and not overly expensive, which may not be the case for you.