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First Rib Resection - understanding side effects after surgery

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Ski2016
Ski2016

In October 2015, I underwent a first rib resection after being diagnosed with Venous Thoracic Outlet Syndrome (Subclavian Compression v. Nueral Compression). My case was fairly urgent as the blood flow was limited to roughly 10% thru my subclavian vein. I was very lucky as I did not experience any typical symptoms such as a swollen arm due to clotting. I originally went to the doctors because I had a pain in my lower abdomin, which I thought was pneumonia coming on. I tested positive for D-Dimer (results around 2.0+), therefore my doctor immediately sent to get a CT Scan to rule out a blood clot. I did not have a blood clot, but this is when they did discover the unusually narrow vein. The doctor advised I see a Thoracic specialist. 

The surgery went well. I was in the hospital for 2 nights. Recovery took about 4-6 weeks before I could go back to work full-time. I underwent PT for about 2 months, starting 1 month after surgery. 

However, since October I have experienced a number of side effects including:

1. Horner's Syndrome. My right pupil (side of surgery) is still noticably constricted. 

2. Numb arm due to damage of the long thoracic nerve, a constant roller coaster of sharp, acute pain and soreness near my right breast bone (I had my right first rib taken out). I want to understand if the pains I am feeling 6 months later are a normal part of nerve regeneration and if anyone has a similar experience, how long they last? The pain seems to come on and off all day. Some pains (acute/shooting) mainly in the mid-section of my right arm. The under side of my arm is still numb to touch.

3. Another pain I experience is near my second rib, where it attachs to the breastbone. A lower position then where my first rib was taken out, so I find this strange, the irriation would be lasting this long.

4. About 2 months ago, I started getting sharp pains in my upper lung (is the best way to describe it). When I drink cold water or other beverages it sends a sharp pain to the area. It is very strange.

5. Stuffy nose at night. Since surgery I can not breathe through my nose fully. It feels stuffy and not clear. 

I have been to a few typical follow up appointments but my surgeon has not been able to identify a detailed reason for these pains besides a side effect of surgery. I understand my body underwent an intrusive surgery and needs time to heal, but I often get worried now something else is wrong, since the pains come on so suddenly and sharp, six months later. 

We do not know the reason for the development of the VTOS. One of my surgeons suggested it happened when I was young, as the network of blood vessels around the vein were enlarged and carried much of the blood not flowing through my subclavian vein. The main surgeon thinks it may have happened within in the last 5 years. Typically trauma or excessive overhead movement causes VTOS, however neither of these applied to my case. 

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  • Heybeth
    Heybeth Ski2016

    Posted

    Hey, I had both of my first ribs removed. The left one when I was 27, and the right one when I was 29. 

    May 2012 - Blood clot identified in left subclavian vein. Warfarin prescribed. 

    June 2012 - Angio, Cath delivered TPA and Heparin to break up clot. 

    December 2012 - Removal of Left First Rib 

    May 2013 - Off of Warfarin 

    Prior to April 2014, pretty lazy lifestyle, out of shape, but not all that limited in functionality. 

    April 2014 - Began CrossFit (That will be important later ... ) 

    July 2014 - Swelling and Edema associated with overhead lifting

    August 2014 - Removal of Right First Rib; begin xarelto

    October 2014 - Back at CrossFit (with embarrassingly small pink weights that I had to buy for myself since the gym had no 2 or 5 pound dumbbells) 

    November 2014 - Off of Xarelto 

    Feb 2015 - CrossFit Open - Scaled Workouts

    Feb 2016 - CrossFit Open - RX Workouts 

    All of that background information is provided so that when I say --- It gets better --- you know that I really get it. My first surgery took a long time to recover from; I could not touch my ear to my left shoulder for 5 months. After my second surgery, it took me 4 days to have the mobility to raise my right arm directly overhead and touch my shoulder to my ear. I was getting smoked in all workouts for a long time, but now, (almost 2 years later, which I know seems like forever, but passes more quickly than you would guess) I can fully participate in everything and the only real limitation I have is that I have to warm up a little longer for overhead lifting and my snatch grip is narrower than my coach would like. Beyond that though, I regularly have my own bodyweight overhead, I can kip (which took a long time to get the mobility for), and my only excuse for slow burpees is that it's hot and I am tired. Best of luck with recovery!!! Slow and steady is all it takes to eventually get better!

    Also, the sharp pain that I have seen mentioned above happened to me as well. In my case it was a "floating rib head" which is where the rib sort of slips so that it is not articulating against the vertebrae correctly. So painful - stabbed every time I moved! It was corrected with a few trip to the chiropractor and some core exercises. It never bothers me anymore! I think it was related to the chest tube that I had after the second surgery; they can stretch the intercostal muscles a bit. 

    Anyway, let me know if you have any questions! Recover well! 

    • Ski2016
      Ski2016 Heybeth

      Posted

      Thank you for the detailed reply! I am really happy to hear you are essentially back to full recovery even if a 3 year or so process. Good for getting back to RX wods smile Very interesting on the floating rib head. I am going to try acupunture and if ever needed will ask about the chiropractor. 

      I did find out that about 80% of VTOS patients go back in to remove the first rib on the other side, odd right? My surgeon said if its not bothering me, you can wait for surgery since it is not as severe at my first case. It is also the neuro version versus venous so its not life threatening just odd for my left arm to go numb. 

       

    • leah14886
      leah14886 Heybeth

      Posted

      HI, I am nor having numbness and tingling in my right arm in certain positions. It's a little over two months since my first rib resection on my left side. I'm recovering well, barring a tiny bit of ongoing pain. I'm concerned about having to get it done on my right side now too. If I have to I'd rather just go ahead and do it instead of waiting. Did you have symptoms on your second side afte or before your surgery? Did you tell your doctors? Did you have a blood clot on the second side or just swelling? Thanks...I'm feeling pretty anxious
    • leah14886
      leah14886 Ski2016

      Posted

      Hi! I am wondering where you got this number of 80% having to have the second side done, I am concerned about my rigt side and can't seem to get doctors to take me seriously, if I could present them with some numbers like that I feel like I'd have a better shot smile thanks!
    • Ski2016
      Ski2016 leah14886

      Posted

      The 80% came from my surgeon at Brigham &Womens hospital in Boston- One of the best hospitals. I was surprised he informed me of this statistic post surgery, obviously it is a case by case scenario but it seems odd there is not more research why it occurs in the second side later- if not related to a trauma incident.
    • roger45144
      roger45144 Ski2016

      Posted

      You know Ski I was thinking of that also which I have come to the conclusion that after the first surgery you tend to use the other arm more like I am doing now due to the paralyzed shoulder but can do with surgery in general, you hurt on that side so over work the other. Symptoms usually appear in the dominant arm right. Take that away and you use the the other. I started having symptoms in my other side soon after surgery. That's just my thoughts on the matter and my primary care MD does think that also.
    • leah14886
      leah14886 Ski2016

      Posted

      Thank you! I've been trying to get my primary care to take me seriously about screening. I'd like to avoid another blood clot, the idea is terrifying. I really appreciate the info.
    • Ski2016
      Ski2016 leah14886

      Posted

      Of course, we as patients have to be proactive about our own health. My opposite arm started going numb during sleep post surgery, so clearly I was vey concerned and went to the doctors after 4 months post opt(when he told me statistic) and advised my pcp. My surgeon said it was likely I developed TOS on opposite side but the nerve based version hence why my arm was falling asleep. In this case, it was not threatened since my nerve was being pinched v a vein with blood. It has gotten much better however over the last view months so I have not visited the Nuerosurgeon specialist whom my pcp and surgeon recommended seeing if it continued. He did not push me to get surgery, he only said to get surgery on second side if it is effecting my daily life. I am not going to get surgery, atleast yet as my recovery was long from the first and my right arm has not fully healed yet, i.e. Nerve regeneration.

    • leah14886
      leah14886 Ski2016

      Posted

      Yeah, it seems very very important to advocate for yourself with doctors. As I said in another thread, I had to see 4 doctors before anyone helped me with my blood clot. Once I found the right ones they were very good. I don't want any nerve problems but I'm ok with that, it's the DVT & PE's that scare me...I can deal with lots of things as long as I'm gonna live 😊 It's not having the chance that scares me l!
    • leah14886
      leah14886 Ski2016

      Posted

      HI again Ski, would it be possible to private message me your surgeons name so I could speak to him directly or even have my GP communicate with him? I just do not forsee being taken seriously and it is incredibly important to me. Thank you.
  • rdizzle92
    rdizzle92 Ski2016

    Posted

    Hello my name is Robert.  I live in Canada.  I am in my early 20s.  I lift weights frequently have broad shoulders, swim, play basketball etc.  I am A very active person.. Recently I wanted to take up the sport of cycling so I purchased a Road Bike.  I loved riding my bike and would go on multiple hour rides.  This is where I believe my problem started and where I really aggrevated my underlying VTOS which I had no idea I had.  Road bikes put you in a very aggressive bent over stance putting a lot of your bodyweight on your arms and hands.  One day I woke up and my left arm was completely swollen. I initally ignored it thinking perhaps it was just a muscle strain as I overexert myself in upper body workouts at the gym often. After a day or two it did not go down so I went to my family doctor.  My family doctor gave me a requistion for an ultrasound.  This was on Saturday and there were no clinics open.  Even when I went to the Emergency Department their diagnostic imaging radiologists do not work on weekends.. So I had to wait until Monday to get tested.  However, the ER doctor did a blood test and my D-Dimer was 2216 (normal range is < 500).  er doc gave me a 20 mg xaerlto and scheduled the u/s the following day... u/s concluded i had a dvt in my subclavian vein and axillery vein.  transferred to a vasuclar specialist and did the following treatment.  cathertered directed tpa (clost busting medicine) at dvt site with a 20cm line. they infused this in the clot area for almost 72 hours while on heparin.  everyday in the hospital i noticed the swelling going down and my arm improving.  did venograms with x-ray and contrast to check progress on the clot every 24 hours.  after about 3 days majority of the clot was dissolved and i was taken off the tpa and heparin and flipped over to oral anticaggulation (xaerlto).  was discharged a few days later.. since discharge i have been very mindfull with how i use my left arm trying to avoid situations of raising my arm above my head at all costs.  the swelling still has not completely gone away it is still noticably larger than my right.  i believe i am suffering from pts (post thrombotic syndrome).  my next appointment with the thoracic surgeon is a month away.  i just want to know how compressed my veins are. while i was in the hospital doctor ballooned my vein.  when he raised my arm above my head the vein blood flow was completely cut off.    i have returned to exercise but only cardio. i find focousing on your posture while sitting down really helps aleviate some pressure in that area.. i think i will start doing some back workouts to strengthen my deltoids and rhomboids to better correct my posture.  i am really hoping that i can get the decompression surgery so i can have normal blood circulation.

      500).=""  er="" doc="" gave="" me="" a="" 20="" mg="" xaerlto="" and="" scheduled="" the="" u/s="" the="" following="" day...="" u/s="" concluded="" i="" had="" a="" dvt="" in="" my="" subclavian="" vein="" and="" axillery="" vein.=""  transferred="" to="" a="" vasuclar="" specialist="" and="" did="" the="" following="" treatment.=""  cathertered="" directed="" tpa="" (clost="" busting="" medicine)="" at="" dvt="" site="" with="" a="" 20cm="" line.="" they="" infused="" this="" in="" the="" clot="" area="" for="" almost="" 72="" hours="" while="" on="" heparin.=""  everyday="" in="" the="" hospital="" i="" noticed="" the="" swelling="" going="" down="" and="" my="" arm="" improving.=""  did="" venograms="" with="" x-ray="" and="" contrast="" to="" check="" progress="" on="" the="" clot="" every="" 24="" hours.=""  after="" about="" 3="" days="" majority="" of="" the="" clot="" was="" dissolved="" and="" i="" was="" taken="" off="" the="" tpa="" and="" heparin="" and="" flipped="" over="" to="" oral="" anticaggulation="" (xaerlto).=""  was="" discharged="" a="" few="" days="" later..="" since="" discharge="" i="" have="" been="" very="" mindfull="" with="" how="" i="" use="" my="" left="" arm="" trying="" to="" avoid="" situations="" of="" raising="" my="" arm="" above="" my="" head="" at="" all="" costs.=""  the="" swelling="" still="" has="" not="" completely="" gone="" away="" it="" is="" still="" noticably="" larger="" than="" my="" right.=""  i="" believe="" i="" am="" suffering="" from="" pts="" (post="" thrombotic="" syndrome).=""  my="" next="" appointment="" with="" the="" thoracic="" surgeon="" is="" a="" month="" away.=""  i="" just="" want="" to="" know="" how="" compressed="" my="" veins="" are.="" while="" i="" was="" in="" the="" hospital="" doctor="" ballooned="" my="" vein.=""  when="" he="" raised="" my="" arm="" above="" my="" head="" the="" vein="" blood="" flow="" was="" completely="" cut="" off.=""  =""  i="" have="" returned="" to="" exercise="" but="" only="" cardio.="" i="" find="" focousing="" on="" your="" posture="" while="" sitting="" down="" really="" helps="" aleviate="" some="" pressure="" in="" that="" area..="" i="" think="" i="" will="" start="" doing="" some="" back="" workouts="" to="" strengthen="" my="" deltoids="" and="" rhomboids="" to="" better="" correct="" my="" posture.=""  i="" am="" really="" hoping="" that="" i="" can="" get="" the="" decompression="" surgery="" so="" i="" can="" have="" normal="" blood="" circulation.="">

     >

    • roger45144
      roger45144 rdizzle92

      Posted

      I used to lift and maxed out at 260 5'10 when I reached about 30, that's when I started having a lot of trouble with memory issues musle weakness ect. It has taken me years of testing to get where you are now. If they haven't already even though they are saying atos they really should check a few more blood test for an auto immune disorder. My case it was lupus anti coagulation. I would have them do an arthritis panel along with your regular blood work just to rule out any other conditions man. Doctors do miss things and a lot of times you have to ask. Remember they work and most times you have to do the research and take it to them. Hopes that's helps.
    • leah14886
      leah14886 rdizzle92

      Posted

      Glad the clot has been dissolved. I had a very similar situation a few months ago but had an immediate rib resection (the day after clot was dissolved) I suggest you try to move up your appointment with your surgeon if at all possible. Once I recovered most functional usage of my arm/hand post surgery my physical therapist started me on strengthening my serratus anterior and weak lower traps (I had been compensating with my scalenes and delts). I'm not sure if that is what everyone needs but I think the traps are standard. As for cardio, I really believe all my exercise prior to surgery greatly reduced my recovery time. I had surgery on a Friday and was home by Sunday, walking around my neighborhood that evening. I feel incredibly lucky about this but also believe my overall fitness really helped (also amazing surgeons) good luck, take care, let me know if I can offer any insight. I only know my own experience but am happy to share it, I know finding reliable info on such a rare condition is beyond frustrating.
    • roger45144
      roger45144 leah14886

      Posted

      See my surgeon said the totally different, with the scalinectomy because of musle mass that more time had to be taken. With that I do have to add that I am in my 40's now and was in pretty good shape. I have lost 26 lbs since all muscle mass but have always been broad across my shoulders and no neck until surgery. Now on one side I actually look like I have a neck, lol the other side is still the same (cervical rib still in place). Even my wife has committed about the difference. Could be the age difference and length of time with symptoms idk well see when I go back. I'm 5 months out now and still don't have the use of my shoulder. Can't even lift a paper plate. Glad you guys are doing well just don't over do it.
    • rdizzle92
      rdizzle92 leah14886

      Posted

      Thanks for the response and your insight.  I am a very anxious person and I could barely cope with them putting a cathether in my vein I do not know how I am going to get through the first rib resection even under G/A. May I ask how long was your procedure, did you feel any pain, what was the post op care like.  I have also heard this surgery does have its risks/complications such as nerve damage.  Thanks again 
    • roger45144
      roger45144 rdizzle92

      Posted

      I hade a lot of complications after surgery so probably not the best one due to anxiety. Speak with a few other persons here about 99% it seems have done well just think I was unlucky with the surgeon that I had. As of surgery it's self if they know you are anxious, they will fix that going in. As of after care the hospital staff I had was excellent, most people spend about 1-2 days in hospital but mine was a week. This was because of prior health problems and complications I had. Just read through the post and you will get a better idea but surgery it's self was not bad. That's what I was so anxious about.
    • leah14886
      leah14886 rdizzle92

      Posted

      Hi!! I have a lot of preexisting anxiety problems as well. This experience exacerbated them initially but I'm hopeful it is ultimately going to help me deal with them. That said, for me, the anxiety has been the worst part. As for G/A, that's easy-the anxiety pre op is awful, but unless you plan on running, it is what it is...after you get it your out. It's easier than the catheter because essentially that time just disappears. I'd say I was in OR for about 5 hours. Afterwards, I had pain in my chest and neck but mostly behind my shoulder blade. I hated the meds and started half doses that night. I was in the hospital for 2 more days and never took any of my prescription pain medication once I left. That stuff scared me and opioids create dependence-I'm not into that and luckily the pain I had was easily managed with over the counter stuff. As I said, I was out walking at least once a day immediately-probably at least 3 miles everyday. I really think this sped my recovery. Pain and aching continues, I have a lot of muscle spasms in my chest and aching in my shoulder and arm. It's not that bad, only a scary reminder, I think that is part of my nerve damage. I still get parasthesia in my arm, which was a major symptom I ignored and wrote off as anxiety for years...my physical therapist thinks that ignoring it for so long may have caused permanent damage. It's ok, I don't mind- that's just the way it is now, it's the idea that it's some sort of "sign" of things to come that scares me...I just wish I had listened to my body instead of assuming I was crazy. Get a therapist. That's what I've needed most. I was very weak and swollen and essentially ignored/misdiagnosed for days by doctors (the nurses always got it though) and sent home. I was terrified I was going to die,I knew I had a blood clot but no one could find it. I essentially self diagnosed through Internet searches and phone calls to hospitals. Finally the sports medicine orthopedist I walked into knew what was up...I already had some PTSD from childhood trauma, this experience brought it back to the surface. I'm trying to deal with both this and my childhood stuff in therapy now. Wow! Long story, lots of meandering. I hope I was able to answer your questions (and then some 😉) as I said, just my experience and everybody is different. Good luck and let me know if I can help. Have a great day!!
    • Ski2016
      Ski2016 rdizzle92

      Posted

      Thank you for the detailed Robert! I live in the us, so the readings for d-dimer are slightly varied., < 0.5="" normal="" range.="" my="" reading="" was="" at="" 2.1,="" which="" sounds="" like="" ratio="" wise="" is="" very="" similar="" to="" yours,="" however="" i="" was="" very="" fortunate="" and="" did="" not="" clot.="" my="" vein="" was="" restricted="" to="" about="" a="" 10%="" flow="" when="" arms="" raised="" above="" head="" ,="" so="" surgery="" was="" necessary="" at="" that="" point="" due="" to="" the="" dynamic="" flow.="" it="" was="" not="" safe="" risking="" a="" clot="" so="" close="" to="" the="" heart.="" i="" assume="" if="" your="" surgeon="" has="" not="" suggested="" or="" pushed="" it="" is="" likely="" at="" a="">50% flow . That is when my surgeon says they start considering a first rib resection. However a clot is a clot and I would be concerned in your shoes, but I am glad you are back exercising within reason. It was definitely a mental block for me to get back to excerise during the few weeks I waited to get the procedure. I am very active and it's tough holding back.
    • Ski2016
      Ski2016 rdizzle92

      Posted

      forgot to say a few things smile if had you get an CT scan or cat scan I would just ask for the surgeon to review it with you. That is what mine did and it was very helpful looking at the screen shots myself. He was able to tell me how much it was constricted because they gave me the contrast dye during scan making it very easy to reAd. Just ask and be proactive!
    • IndigoBall
      IndigoBall roger45144

      Posted

      Anyone else in this group acquire a surgical site MRSA infection!?
    • roger45144
      roger45144 IndigoBall

      Posted

      Is that what they figured out where your pain wads coming from? Is it in the tissue, bone or both.
    • IndigoBall
      IndigoBall roger45144

      Posted

      No, it isn't responsible for all my pain.

      About 10 days after surgery, the wound starting becoming more painful and within a couple of days it was obviously infected. I went to my primary doctor's office for a culture and was started on an antibiotic. I followed up with my surgeon's office. After seeing images of my infected wound that I shared with them via email over a couple days, they decided they wanted to check the wound themselves so sceduled me for yesterday. Over the weekend I received the results from the culture which was positive for MRSA. Although the culture results indicated that the MRSA was not resistant to the antibiotic I was put on, my infection continued to progress around the surgical incision ...which had opened a little and draining a bit in that area. I went in for my appointment yesterday after 6 days of being on the antibiotic and they decided to try another antibiotic according to my culture results instead. Apparently it's no big deal to them .... but I sure always thought MRSA was a big issue.

      I'm scheduled for my surgery follow up, including XRAYS, on Thursday. They will check for any progress then.

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