Neurogenic Thoracic Outlet Syndrome Allen J. Togut, MD
Disclosure
Nothing to Disclose
Learning Objectives Describe the pathogenesis of neurogenic thoracic outlet syndrome Explain how the neurological examination is used to diagnosis the syndrome Identify the role of the patient in the evaluation and treatment Describe three treatment options for neurogenic thoracic outlet syndrome
Questions? 1. Neurogenic Thoracic Outlet Syndrome a. b. c. d.
Is a figment of the surgeon’s imagination Is ruled out with a normal Electromyographic/ Nerve Conduction Study Is over diagnosed Is the resultant of trauma(s) superimposed on underlying anatomical variations in the inter scalene triangle area
Questions? (cont’d) 1. Neurogenic Thoracic Outlet Syndrome a. b. c. d. e.
Is the result of the inability of the brachial plexus to glide Is due to a chronic inflammatory process of the brachial plexus Is made worse by repetitive use of the extremity Is a neuropathic pain condition All of the above
Questions? (cont’d) 3. In neurological testing of a patient with neurogenic thoracic outlet syndrome one a. Checks to see whether the brachial plexus is able to glide b. Examines the brachial plexus and peripheral nerves for irritability c. Evaluates for sensory loss d. All of the above
Questions? (cont’d) 4. In assessment of neurogenic thoracic outlet syndrome it is important to a. b. c. d. e.
Know the dynamics of the injury Review past management Inquire about marital relationship Determine how well the patient is coping All of the above
Questions? (cont’d) 5. In the management of neurogenic thoracic outlet syndrome a. b. c. d. e.
Resistive exercises always help Surgery is indicated Psychological evaluation is indicated to rule out malingering Narcotics are rarely indicated for relief of pain Treatment is a function of what is learned using the biopsychosocial assessment
Thoracic Outlet Syndromes-3 Neurogenic: by far (95%-97%) the most common Vascular-compression of the subclavian artery between the clavicle and the first rib usually in the presence of a cervical rib presents with weakness of the arm on abduction and peripheral emboli. May represent an emergency situation Vascular-compression and subsequent occlusion of the subclavian vein between the clavicle and first rib in setting of expanded subclavian tendon and or a more anterior insertion of the anterior scalene muscle on the first rib undergirding the vein -presents with thrombosis of the vein. An emergency (Paget-Schroetter Syndrome)
Neurogenic Thoracic Outlet Syndrome Chronic neuropathic pain condition involving the brachial plexus where it is restrained by scar and is highly irritated Mainly a sensory nerve injury-a-delta and c-nociceptive fiber injury (key) Results in pain and paresthesias as the principal initial symptoms Motor function is impacted by a-delta fiber dysfunction In a small percentage of cases motor function is usually lost by compression of the motor nerves by a cervical rib
Neurogenic Thoracic Outlet Syndrome (N-TOS) The diagnosis is a clinical one The diagnosis is made by having symptoms which are suggestive of it and by being able to reproduce those symptoms on neurological examination Laboratory findings should only be used in the context of the clinical findings
Brachial Plexus─Anatomy Represents the ventral rami of the spinal nerves C-56-7-8 and T-1 C5 and 6 combine to form the upper trunk and with a branch from C7-the lateral cord C7 represents the middle trunk and receives branches from the upper and lower trunks C8 and T1 form the lower trunk-medial cord
Brachial Plexus─Anatomy (cont’d)
Netter, F. Atlas of Human Anatomy. Third Edition.2004. Icon Learning Systems. Teterboro, New Jersey. Plate 413. Permission granted.
Brachial Plexus─Anatomy (cont’d) C5 and C6 pass through the anterior scalene muscle C7 passes deep to the anterior scalene muscle as does C8 and T1 The plexus then passes through the inter scalene triangle-anterior and middle scalene muscles make up the sides of the triangle with the base being the first rib
Axilla─Anterior Dissection
Netter, F. Atlas of Human Anatomy. Plate 412. Permission granted.
Brachial Plexus─Anatomy The plexus travels under the clavicle over the first rib with the subclavian artery Both move under the pectoralis major and minor muscles exiting them and entering the axilla
N-TOS-Anatomy plus Trauma Anatomy
–Scalene muscle variations, scalene minimus m. –Complete , incomplete cervical rib ( Type 1 band) –Long transverse process of C7, longer than that of T1( Type 2 band) –Other bands –Long neck, short person- females/males 3:5:1 –Clavicular fracture with callus –Pancoast tumor (superior sulcus of the chest)-initially involves the lower trunk of the brachial plexus
Pathogenesis of N-TOS Trauma(s) –Motor vehicle accident (whiplash associated disorder) –Cumulative trauma disorder as in an assembly line worker –Falls
Diagnosis Gold standard is an exquisitely taken history and a well done physical and neurological examination Reproduction of the symptoms, indicative of N-TOS by neurological examination, gives concordance and the diagnosis
Diagnosis (cont’d) Impact of the illness and the ability of the individual to cope is a critical part of the assessment and subsequent clinical management which needs to be determined at the onset Evaluate extent of the losses patient has sustained and how well the individual is coping
Neurogenic Thoracic Outlet Syndrome-N-TOS Symptomatology and etiology Neurological examination Laboratory testing Clinical management
First (and Last) Statements Need a diagnosis(s) Need to know the story Need to know the pain-suffering basis Need to know how the individual is coping Need to know role of narrative medicine Carr, D., Loeser, J. and Morris, D. Eds. Narrative, Pain, and Suffering. Progress in Pain Research and Management. Vol.34. IASP Press, Seattle, Wa.2005.
Symptomatology Brachial plexopathy-neurogenic thoracic outlet syndrome can be divided into 3 major involvements –Lower plexus –Upper plexus –Entire plexus
Lower Plexus-C8, T1-Lower Trunk-Medial Cord Brachial Plexus Pain from neck across the supra clavicular fossa and clavicle onto anterior chest wall Pain down the inner arm, ulnar forearm (hand supinated) with tingling and numbness of the ring and small fingers-may include ulnar surface of the long finger-ulnar nerve territory With dysfunction of the hand-dropping things, and the extremity Made worse by the use of the extremity in work and activities of daily living
Cutaneous Innervation of the Upper Extremity
Netter, F. Atlas of Human Anatomy. Plate 464. Permission granted
Brachial Plexus
Netter, F. Atlas of Human Anatomy. Plate 413. Permission granted
Dermatomes
Netter, F. Atlas of Human Anatomy. Plate 465. Permission granted
Intercostal-Brachial Cutaneous N. Exits between the 2nd and 3rd ribs in the midaxillary line and joins the cutaneous n. of the arm It adds to the symptom complex frequently giving anterior chest wall, axillary and posterior arm pain, suggesting an acute myocardial infarction On the right side-unlikely But on the left side concern because of the associated pain down the arm into the hand and fingers
Axilla-Anterior Dissection
Netter, F. Atlas of Human Anatomy. Plate 412. Permission granted
Brachial Plexus-Upper Trunk-Lateral Cord Pain from neck down medial scapula border Pain onto the anterior chest wall Pain down anterior brachium, radial forearm (hand supinated) With tingling and numbness of thumb, index and long fingersmainly median nerve territory With dysfunction of the hand-dropping things and the extremity Made worse by the use of the extremity in work and activities of daily living
Cutaneous Innervation of the Upper Extremity
Netter, F. Atlas of Human Anatomy. Plate 464. Permission granted
Brachial Plexus-Upper Trunk-Lateral Cord C-5 gives off the dorsal scapular n.-supplies rhomboid major and minor muscles (m) C-5 and C-6 combine to make the upper trunk The upper trunk gives off the suprascapular n.-innervates both supra and infraspinati m. C-7 gives a large branch to make the upper trunk the lateral cord (lateral to the subclavian artery) Lateral cord gives off the lateral pectoral n.-supplies, with medial pectoral nerve, the pectoralis major m.
Brachial Plexus
Netter, F. Atlas of Human Anatomy. Plate 413. Permission granted
Brachial Plexus─Lateral Cord Lateral cord then terminates as it divides into Musculocutaneous n.(C5,6 and 7) and Lateral branch joining the medial branch from the medial cord making the median n.(C5-T1)
Neurogenic Thoracic Outlet Syndrome─Blend
Both upper and lower plexus involvement Before discounting the symptoms the patient has See if it fits a blend
Etiology Resultant trauma (s) lead to both scar-traction type of entrapment Associated with muscle spasm of the parascapular and paracervical muscles and fascial tightness with traction on the brachial plexus
Etiology-Nerve Trauma Trauma to the neck results in hemorrhage, edema of the nerves, muscles and surrounding tissues and subsequently with healing scar entrapment A-delta and c-fibers, the two nociceptive fibers which signal the somatosensory cortex of tissue trauma and where pain is perceived, are the most vulnerable to injury The c-fiber is contained in the epineurium as well as in the nerve bundles with the a-delta fibers The a-alpha fibers which innervate muscles are much larger and therefore more resistant to injury
Etiology-Change in Muscle Dynamics Trauma, whether it be –Single, as in whiplash-rear ended being the most common or –Multiple, as in cumulative trauma disorder (repetitive strain disorder) as in an assembly line worker –Causes injury to muscles –Some muscle become overused, spastic with trigger points, some are under used
Change in Muscle Dynamics Overused/underused muscle creates a muscle imbalance between the shoulder, the neck, and the brachial plexus The trapezius, the levator scapula, the rhomboid major, the sternocleidomastoid, and scalenes (both anterior and middle) become over used, spastic, fatigue more rapidly and do not support the shoulder as well and cause the first rib to be elevated, respectively Mackinnon, S., Novak, C. Pathogenesis of Cumulative Trauma Disorder. J. Hand Surg. 1994;19A. 873-883.
Etiology-Trauma Continues Resultant of this is that the shoulder falls, usually downward and forward, the head rides forward may be pulled to one side and the brachial plexus not only gets pulled─traction─but also restrained by the changing dynamic Further trauma –Continued work on the assembly line – Physical therapy of the resistive exercises type will continue to exaggerate the situation Leffert, R. Thoracic Outlet Syndrome and the Shoulder. Clinics in Sports Medicine.1983; 2.439-452.
Trapezius Muscle: Coat Hanger of the Shoulders
Simons, D., Travell, J and Simons, L . Myofascial Pain and Dysfunction-The Trigger Point Manual. Vol.1. Second Edition. Williams and Wilkins. Baltimore, Maryland. 1999. Figure 6.5. Permission granted.
Etiology of the Trapezius Muscle: Coat Hanger of the Shoulder
Trapezius
Levator Scapula Muscle
Simons, D. et al. figure 19.2. Permission granted.
Rhomboid Major and Minor Muscles
Simons, D. et al. figure 27.2. Permission granted.
Sternocleidomastoid Muscle
Simons, D. et al. figure 7.2. Permission granted.
Scalene-Anterior and Middle Muscles
Simons, D. et al. figure 20.2. Permission granted
Muscles-Underused Trapezius: middle and lower fibers Serratus anterior
Anatomical Variations in the Inter Scalene Triangle Single scalene muscle (anterior and middle fused) with the brachial plexus exiting through the muscle were it might be tethered by the muscle Varying degrees of fusion Anterior and middle scalene muscles meeting on the first rib (usually they have separate insertions) and the plexus and subclavian artery riding over them (type 4 band) C-5 and 6 normally pass through the anterior scalene muscle and may be tethered by the muscle Liu, J., Tahmoush, A. Roos, D. and Schwartzman, R. Shoulder-arm pain from cervical bands and scalene muscle abnormalities. J. of Neurological Sciences. 1995;128.175-180.
Additional Anatomical Variations in the Scalene Triangle 1. Long transverse process of C-7 with associated band (type 2) inserting on the first rib 2. Incomplete cervical rib–type1 band 3. Complete cervical rib–both 1, 2, and 3 insert on first rib at posterior extreme of anterior scalene m. insertion. 4. Scalene minimus m. inserting on first rib between the lower trunk of the brachial plexus and the subclavian artery (type 5 band) or on Sibson Fascia (type 6 band) Roos, D. Congenital Anomalies Associated with Thoracic Outlet Syndrome. Symptoms, Diagnosis and Treatment. Am. J. Surg. 1976: 132:771-8.
Cervical Rib
Incomplete Cervical Rib–Type 1 Band
Luoma, A. Nelems, B. Thoracic Outlet Syndrome-Thoracic Surgery Perspective. Surgical Management of the Peripheral Nerve Injury and Entrapment. Neurosurgical Clinics of North America.2: 187-226, 1991. figure 6. Permission granted.
Long Transverse Process of C-7 (Type 2 Band)
Luoma, A & Nelems, B. Figure 7. Permission granted.
Long Transverse Process of C-7 Vertebra
Type 3 Band
Luoma A & Nelems, B. figure 8. Permission granted.
Overlapping Insertions of Anterior and Middle Scalene Muscles–Type 4 Band
Luoma, A & Nelems, B. Figure 9. Permission granted.
Scalene Minimus m. Attached to First Rib–Type 5 Band
Luoma, A & Nelems, B.figure10. Permission granted.
Scalene Minimus m. Inserting on Sibson Fascia–Type 6 Band
Luoma, A & Nelems, B.figure11. Permission granted.
Etiology Define the trauma(s) with a detailed: –Story (dynamics) of the accident(s) and subsequent –Assessments and treatments documenting if they helped or make the clinical situation worse and what was the change in the symptom complex with time
Etiology (cont’d) Symptoms frequently change and give evidence not only to a changing diagnosis but frequently –To changes in the ability of the patient to handle it –To changes in doctor-patient relationships of a very negative valence
Neurological and Physical Examination Posture- position of shoulders and neck and head Parascapular muscle tenderness and trigger points Nerve Tension Test Tinels? –Brachial plexus at Erb’s Point –Ulnar n. at cubital tunnel and Guyon’s canal –Median n. at pronator teres tendon and carpal tunnel –Radial n. at Arcade of Froshe
Neurologic-Nerve Tension Test Concept-the brachial plexus is trapped. It does not glide Therefore, it will not move without the patient complaining of pain and paresthesias –Nerve tension test- Is performed by asking the patient to tilt their head to the right. This will put tension on the left brachial plexus. Then, at the same time, the patient abducts the left upper extremity to 90 degrees or as far as they are able. You ask the patient after each part of the maneuver what they are experiencing. For the left brachial plexus you do the opposite maneuver. –Dr. Hunter’s maneuvers- see reference Whiteneck, S and Hunter, J. Thoracic Outlet Syndrome: A Brachial Plexopathy. Chapter 49. In Hunter J. et al. Rehabilitation of the Hand, Surgery and Therapy. Mosby Year Book Inc. St. Louis, Missouri. 1995; 857-884.
Nerve Tension Test If the plexus does not glide, then, with the first maneuver, the patient will complain of pain in the contralateral neck and perhaps pain down that arm with tingling and numbness of the fingers With the second maneuver either the radiation down the arm will occur and the fingers will tingle or the findings, if they were present on the first maneuver, will get worse
Tinels Concept- the brachial plexus and one or more of the peripheral nerves is highly irritable. They do not like to be pressured Gently apply pressure to the plexus above the clavicle at Erbs Point (union of C5&6 nerve roots). This is a spot just lateral to the anterior scalene muscle above the clavicle and record their response Then test –Ulnar n. at the cubital tunnel and at Guyon’s canal –Median n. at the pronator teres and the carpal tunnel and –Radial nerve at the Arcade of Froshe (supinator muscle)
Brachial Plexus-Erb’s Point
Netter, F. Atlas of Human Anatomy. Plate 412. Permission granted.
Upper Extremity-Arterial and Nerve Supply
Netter, F. Atlas of Human Anatomy. Plate 456. Permission granted.
Elevated Arm Stress Test-3 Minutes (Roos Test) Stress Test: The arms are placed either in the surrender position or at 90 degrees abduction (in order not to stretch the ulnar nerves). The patient then opens and closes their hands slowly and shares with you what is happening (changing). The test may be aborted earlier if they have a lot of pain. What they are experiencing is recorded with the time. A positive test reproduces the patients symptoms.
Sensory Testing In N-TOS there may be sensory deficits which should be defined –Two Point Static Discrimination •Most people, with their eyes closed, can appreciate 2 points placed in the tips of their fingers from 2-3 mm
Sensory Testing (cont’d) A-beta fiber signal the brain position and vibratory signals –Tuning Fork (256 vibrations/second) placed on each ulna and then radial styloids –Determine if there is a difference in strength and –Other responses
Sensory Testing (cont’d) Sensation testing dermatomes C-2 to T-2 with –Brush –Pin •C2,3 &4 represent the cervical plexus and frequently is involved with brachial plexus
Dermatomes
Netter, F. Atlas of Human Anatomy. Plate 465. Permission granted
Sensory-Motor Testing Deep tendon reflexes –A-Delta fibers hardwired into the motor neurons
Neurological Examination Upper Extremity –Posture, including the hand –Scars –Tremor –Allodynia –Hand-edema, posture and position of fingers, temperature, moisture, nails –Motor strength
Hands
Muscle Strength Hands-Jamar Dynamometer-record strength Individual muscles-grading 0-5, 5 is maximum –Ulnar n. innervated • Ulnar intrinsics (dorsal and volar interossei), first dorsal interossei, ulnar extrinsics, abductor digiti quinti, adductor of the thumb, pinch
–Median nerve –Radial nerve
Muscle Strength (cont’d) Deltoid- C5&6-posterior cord, axillary n. Biceps- C5&6-lateral cord-musculocutaneous n. Triceps-C7&8-posterior cord ,radial n.
Etiology-Case 1-Cumulative Trauma Disorder M.R. is a 35 year old female assembly line worker who has worked doing the same job for the same company for 10 years. She is 5 foot 2 inches tall and sorts items from an assembly line which is at breast level and removing items that are defective placing then in a box at shoulder level 2 years ago she began to complain of shoulder fatigue and saw the company doctor
Case 1 The company doctor told her she had a sprain/strain and gave her a non steroidal. But he didn’t change her job description So she continued to do the same repetitive job 8 hours per day, 5 days per week, sometimes with overtime Her shoulder distress got worse and was associated with daily occipital headaches She was falling behind in her job and was not as efficient and productive as she once was. She had previously been cited and praised for her achievement
Case 1 (cont’d) She revisited the company doctor whose diagnosis didn’t change. He sent her to physiotherapy with diagnosis of sprain/strain without direction to the therapist and without a change in her job description The therapy, after 3 weeks, made it worse and her symptoms changed She was having pain that went down between the right scapula and the spine. The pain also traveled down the front of the right arm, radial forearm and she had tingling and numbness of the right thumb, index and long fingers. She began to drop objects with the right hand
Case 1 (cont’d) She again saw the company physician who thought it was carpal tunnel syndrome and left her in work He only examined her hand. She had no muscle atrophy but had a positive tinel over the median nerve proximal to the tunnel. He referred her to a surgeon The surgeon concurred. He did an EMG/NCS which showed slowing of median nerve conduction velocity across the carpal tunnel He recommended carpal tunnel surgery
Case 1 (cont’d) What would you add to the differential diagnosis? What is triggering your suspicion that this patient does not have a carpal tunnel syndrome? Why?
Case 1 (cont’d) The surgeon did a right carpal tunnel release Prior to the surgery the patient was complaining of pain in the right shoulder, down the right arm, down the radial forearm, with tingling and numbness of the thumb, index and long fingers and dropping things with the her (dominant) hand Postoperatively, there was no change
Case 1 (cont’d) She returned to see him 6 weeks later still with the same symptoms and he said you have to be patient and give it more time 3 months later the same conversation took place with the same response Meanwhile, the patient was miserable, not able to work, not be able to do her housework, care for her kids, and deal with husbands needs Things went from bad to worse
Case 1 (cont’d) Subsequently, she saw many other physicians who individually spent, at most,15 minutes with her and could not understand what was the medical problem She became more and more distressed, angry, disconsolate and depressed It was suggested that she see a psychologist to see if this could be in her head
Case 1 (cont’d) Eventually, she was evaluated by an IME (an independent medical examiner) and he felt after a 30 minute assessment, generating a 10 page report, that –He could find no neurological evidence for a problem –That there was no relationship between her symptoms and the work –That she had recovered from whatever illness she had
Case 1 (cont’d) And, moreover, she could return to work doing everything she did before She returned to work She lasted 3 days and could not do the work and was fired
Case 1 (cont’d)
What is very wrong with this case?
Case 1 (cont’d)
This not fiction. All the elements portrayed here, unfortunately, happen more times than I liked to see
A Different Tact What would you have done differently? What would your focus have been from the get- go? Let us go back in time and get it right the first time around
Examination-Physical and Neurological Symptoms-Pain in a certain distribution –Paresthesias affecting certain areas –Symptoms made worse by use of extremities in variety of activitiesactivities of daily living and work –A changing ( decreasing) ability to accomplish tasks and a dysfunctional extremity
Cutaneous Innervation of the Upper Extremity
Netter, F. Atlas of Human Anatomy. Plate 464 (under license)
Vascular Thoracic Outlet Syndrome-Obstruction of the Subclavian Artery With “power failure” as the major symptom Put your finger on the radial pulse and stethoscope below the clavicle on the side being tested Then have the individual slowly abduct that extremity and note change and response to change If there is a diminution of the radial pulse, bruit over the artery and patient complains of weakness of the arm as the arm goes into abduction with final loss of the pulse this suggests that the patient may have a vascular thoracic outlet syndrome
Adson Test-A Test for Subclavian Artery Obstruction (Vascular Thoracic Outlet) Dr. Adson, Professor and Chairman of the Department of Neurosurgery at the Mayo Clinic described the test in 1927 He found in the presence of a cervical rib and or a tight anterior scalene muscle the patient would lose his/her radial pulse by performing his maneuver Adson, A. and Coffey, J. Cervical rib. A method of anterior approach for relief of symptoms by division of the scalene anticus. Ann. Surg 1927;85.839-857.
Adson Test The maneuver is performed by having the patient abduct his/her upper extremity to about 45 degrees and placing it a little behind the trunk, turning the head to that side and doing a Valsalva maneuver –Less likely would the patient develop pain down the extremity and paresthesias
Adson Test (cont’d) If negative, it cannot and should not be allowed to rule out neurogenic thoracic outlet syndrome If positive and the patient develops pain down the extremity with tingling and numbness of the fingers- it is supportive of the diagnosis of neurogenic thoracic outlet syndrome On examination, if negative and alone by itself, it carries no weight and is meaningless
Vascular Thoracic Outlet Syndrome During the Elevated Arm Stress Test (EAST or Roos Test) the patient’s hand on the affected side will turn white and patient will initially complain of severe weakness of the extremity and will want to put the arm down. The patient will not complain of increasing severe pain and paresthesias
Case 2  A 34 year old male without any previous left neck, shoulder or arm symptoms is injured while working for a landscape company. He was moving a tree with its base (dirt and burlap bagbole) with his left arm 20 yards to previously dug hole. The combination weighed about 300 pounds and his head was turned to the right to guide the tree  While moving it he sustained severe pain in his left neck which radiated down across his left shoulder, the anterior surface of his left arm, the radial forearm with tingling and numbness of his thumb, index and long fingers. Immediately, he had difficulty in moving his left arm and dropped thing with his left-his non dominant hand  These symptoms have been present since his injury 26 months ago and have gotten worse
Case 2 (cont’d) How would you evaluate him? What is the most likely diagnosis(s)? What laboratory testing is appropriate?
Case 2 (cont’d) The pain in his posterior neck traveled up the cervical spine and he developed occipital headaches three out of seven days. These headaches and his arm symptoms were made worse by using his left arm in everything he did. He has not been able work since the day of his injury He is divorced and he and his significant other have five children. She has an entry level job paying little He comes to see me angry, in pain and wanting for me to fix him His pain level on a 0 to 10 scale with 10 being the worse imaginable pain is an 8
Case 2 (cont’d) What are the key observations and tests in his neurological examination? What psychosocial issues do you see? How are you going to deal with his anger? Does he have unrealistic goals? Will he need help in long term planning?
Case 2 (cont’d) On my examination he has –An elevated, tender left shoulder –A positive left brachial plexus nerve tension test –Positive tinels over the left (not the right) brachial plexus at Erbs Point, ulnar nerve at the cubital tunnel, the median nerve at the pronator teres and radial nerve at the Arcade of Froshe –A very positive elevated arm stress test with accentuation of all left sided symptoms after ten seconds –Sensory loss- with both the brush and the pin being felt better over the right C5 to T1 dermatomes –Deep tendon reflexes-biceps, triceps and radial periosteals are 1-2 plus and equal
Case 2 (cont’d) EMG/NCS done twice is within normal limits Cervical spine films shows no abnormalities MRI of the cervical spine shows –A herniated disc at C5/C6 with mild right C6 neuroforaminal compression –A herniated disc at C6/C7 with mild left C7 neuroforaminal compression
Case 2 (cont’d) What is your diagnosis? Are there any additional studies needed? What other diagnoses may we have to address? What should we do for him?
Case 2 (cont’d) Course-He saw a neurosurgeon who felt that the C6/C7 disc was the problem and recommended diskectomy and fusion Postoperatively, he was treated with limited motion of his left arm and a hard then changed to a soft neck collar His MRI of the neck was checked at 3 months and the fusion was felt to be solid He was then begun on resistive exercises of his left upper extremity in a work hardening program
Case 2 (cont’d) The symptoms involving his left upper extremity, which had abated in the postoperative period, returned with renewed fury Moreover, he developed the same symptoms in his right upper extremity and his exam showed the same positive findings albeit much milder What went wrong?
Traction Injury to the Brachial Plexus Symptoms are immediate Represents a more severe injury to the plexus Motor loss may be present besides sensory loss History gives the diagnosis Physical findings-pain, paresthesias and limited ability to use the extremity Most severe form is avulsion of a spinal nerve from the spinal cord Hunter, J and Whiteneck, S. Traction Neuropathies of the Brachial Plexus and Its Terminal Nerves, Chapter 50. In Hunter, J at al. Rehabitation of the Hand , Surgery and Therapy. Mosby Year Book Inc. St. Louis, Missouri 1995;885-904.
Neurogenic Thoracic Outlet SyndromeClinical Diagnosis Symptoms are suggestive of the diagnosis-pain from the neck across the shoulder down the arm with paresthesias On physical and neurological examination the symptoms are reproducible by –Nerve tension test- the brachial plexus does not glide –By pressuring the plexus and the peripheral nerves- ulnar, median and radial nerves-they are irritated-positive tinels –By doing the three minute stress test. –And there are sensory deficits
Laboratory Testing All laboratory findings must be viewed from the perspective of the clinical findings EMG/NCS has a 30% sensitivity. But when positive it is supportive. If negative it does not rule out neurogenic thoracic outlet syndrome
Laboratory-SSEP
SSEP-Somato Sensory Evoke Potentials comes closer to defining the site of pathology
Baran, E. SomatoSensory Evoked Potentials. In Hunter, J. et al. Rehabilitation of the Hand, Surgery and Therapy. Mosby Year Book Inc. St. Louis, Missouri. 1995. pp.843-55.
Laboratory-Conduction Velocities and Latencies
Doing conduction velocities and latencies across the upper trunk to the lateral cord of the brachial plexus and Across the lower trunk to the medial cord will give useful information which may support the diagnosis
Cervical Spine X-Rays Cervical Spine X-Rays –Valuable in assessment, particularly the AP view, in that it may show • A long transverse process of C-7, longer than the transverse process of T-1, and downward pointing • This represents an incomplete resolution of a cervical rib and is associated with a band of tissue leaving its distal extreme which goes under the brachial plexus and inserts on the first rib at the posterior extreme of the insertion of the anterior scalene muscle
M.R.I. Cervical Spine M.R.I. of the cervical spine should be performed when the clinical picture is suggestive of a either radiculopathy or cord compression by a disc and or osteoarthritic process The findings may show the anatomic relationships which may or may not correlate with the clinical picture The findings should not supersede the clinical findings The findings should not be used in place of a clinical evaluation
MR Neurography MR Neurography is a special MR with software and protocols which better demonstrates the components of the brachial plexus, the sites of inflammation and compression and their relationship to contiguous structures than the M.R.I. It is also useful in surgical decision making Filler, A. MR Neurography and Brachial Plexus Neurolysis in the Management of Thoracic Outlet Syndromes. In Advances in Vascular Surgery. JST Yao and WH Pearce Eds. Precept Press. 2002; 499-523.
Psychosocial Assessment Losses –Independence –Job –Income –Ability to care for and participate with children and home –Ability to deal with spousal’s needs with a changing interpersonal relationship-divorce –Friends and, frequently, family –Self esteem
Losses Resultants-Feelings –Helplessness –Uselessness –Hopelessness –Depression
Need to be assessed and incorporated into the total evaluation
Management With the information from the biopsychosocial evaluation one has the diagnosis –Neurogenic thoracic outlet syndrome-a restrictive entrapment neuropathy of the brachial plexus –And other diagnoses • Adequacy of pain control • Depression • Sense of self
Management (cont’d) Also appreciated –The impact the illness has had –How the patient is coping? –Support the individual has?
Management (cont’d) Validation-you have a real medical condition Educate about their illness showing what they have in language they will understand That they, not you, will be in charge of and learning about their illness (diary) and modifying what they do so with time they will, hopefully, be able to plateau the symptoms of their illness You will be their guide
Management (cont’d) Review with them what makes their symptoms worse is so they can begin to do activities differently –The repetitive use of their arms –Much above lap level –The longer they do it, the more the distress –The higher they go, the more resistance they work against –The greater the increase in pain, paresthesias, and dysfunction of the extremity
Management-Adapt Useful, but takes time to change Basic principals of –Change-adapt-determine how you will do an activity without making the symptoms worse. An example-if you talk on the phone by holding the phone to your ear or cradling it then either use a headset/speaker phone or blue tooth. If walking with your arms at your sides increases the pain in your shoulders then support your arm(s) with hands in your belt or use a fanny pack
Trapezius-A Major Player Functions with levator scapula as the coat hangar of the shoulder blades It also assists and stabilizes the arm in much of what the arm does In neurogenic thoracic outlet syndrome it usually is overused, spastic and dysfunctional Any increase in use will increase the spasticity and hence the pain So support your traps
Adapt-Trapezius Muscle
Simons, D. et al .figure 6.5. Permission granted.
Pace Pace-listening to your body and do in smaller time frames what you did before when you completed a task at one time –Rest between these time frames so as not to push your illness. Apply heat or ice whichever works best –Do not do several activities right after each other or one activity for a long period of time
Delegate Delegate –Give heavier tasks that you know will accentuate your symptoms to others –Resist the temptation that you can do what you know will put you down for the count –Although many do the activity so that they can feel like they are more normal (frequently denying their illness) and they can participate more equally in their family’s activities they usually only do it once, maybe twice, before they realize that the misery which follows is not worth it
Physical Therapy Diagnosis before therapy “Decrease the inflammatory status within or around the neural tissue by –Rest from function –Avoidance of tension or compression positions and activities –Gentle and frequent neural movement-glide without producing tension”
Physical Therapy (cont’d) “Management of associated musculoskeletal problems that irritate the plexus and prevent normal joint and muscle function but without accentuating the brachial plexus symptoms Restoring normal neural function, musculoskeletal mobility and restoration of tolerance for neural tension –By restoring musculoskeletal strength beginning with aerobic progressing to resistive exercises –Slowly increasing neural tension tolerance –Always listening to the patient and changing when plexus symptoms are provoked” Barbis, J and Wallace, K. Therapist Management of Brachial Plexopathy. In Hunter et al. Eds. Rehabilitation of the Hand, Surgery and Therapy. Mosby Year Book Inc. St. Louis, Missouri. 1995;923-950.
Physical Therapy (cont’d)
Not every patient with neurogenic thoracic outlet syndrome will tolerate or respond to physical therapy
Cognitive Behavior Therapy-CBT Potentially, we have the ability by staying positive in thinking and emotion to modify the pain we perceive Cognitive behavior therapy teaches techniques to assist us to accomplish this goal It helps by reframing questions in positive terms, by showing the power of the individual to use his/her ability to use the mind to decrease the pain and the perception of the pain
CBT It teaches what pain is and how the individual can gain control It teaches how to modify self talk into positive realm It shows why catastrophizing is so destructive and how to change it It implores those who use denial to try to recognize that it serves no useful purpose and maintains them in the past without the possibility of moving forward
CBT (cont’d) It tries to dissuade individuals to avoid wishful thinking for that serves no useful purpose in dealing with their illness It shows how avoidance just limits and isolates the individual It tries to show irrational beliefs for what they are and bring the individual in greater contact with reality Caudill, M. Managing pain before It Manages You. New York, New York. Guilford Press. 2002.222 pg.
Pain Management-Pharmacy If severe unrelieved pain is associated with suffering little will be accomplished unless the pain is modified Not everyone has a high pain threshold, a very positive way of dealing with life’s situation and can handle severe pain The story of the patient’s problem more often than not gives evidence to the pain level-suffering and how the patient is coping
Pharmacy Using the visual analogue (VAS) scale of 0 to 10 –0-being no pain, 10 being worst imaginable pain –Determine what the patient experiences –Also include pain level with activities of daily living –Hours of uninterrupted sleep at night and what wakes them up –Decide what medications are appropriate –Review risk for abuse and diversion
Pharmacy (cont’d) Knowing the pain level-suffering and coping capabilities one appreciates the need for narcotics If the need is accepted both by the physician and the patient then begin with short acting narcotic knowing shortly that you might have to use both short and long acting narcotics Other classes of drugs to be tried include antiseizure, tricyclics, anti muscle spasm
Pharmacy (cont’d) Other issues to be addressed –Anxiety –Depression –Bipolar personality
Advocacy If necessary, we need to help patient advocate for themselves In the present medical milieu physicians frequently either do not have time to talk with patients or do not know how. Information is provided either of too sophisticated a content without explanation or not at all This occurs both for testing and for treatment Patients are frequently in the dark
Advocacy (cont’d) We need to assist patients in encouraging and learning how to ask questions of the health care provider without being turned off They are at times just too intimidated They need to know why are you doing this test? What do you hope to learn from it? They need to know why do you recommend this operation? What will I gain from it? They need to know what the downsides-risks of this operation are and how frequently does complication occur?
Advocacy (cont’d)
They need to know and not be insulted and turned off
Surgery When is the decompression of part or all of the brachial plexus indicated? The patient needs, if surgery is felt to be appropriate, to participate in a benefit/burden discussion Is there more to be gained or loss with surgery? Surgery, generally, does not cure most patients. It improves many, not all
Surgery-Factors to be Considered Pathologies –Scar entrapment –Anatomical variations –Tractions due to paracervical and parascapular muscle dysfunctions
Surgery-Healing and Patient’s Participation? Healing results in a variable degree of scar entrapment which is partially under the surgeon’s control • Hemostasis needs to be secured, the plexus totally decompressed and the area around the plexus needs to be left free of tissue to which it might become adherent
The patient needs to participate in both the postoperative and post discharge period in order to ensure that once the plexus is freed at surgery that it will both continue to glide and that there will not be overuse of the involved muscles
Surgery With an established clinical diagnosis of neurogenic thoracic outlet syndrome the following situations suggest the urgent to less urgent need for surgical intervention: 1. Positive EMG/NCS findings, a cervical rib complex, with or without muscle atrophy 2. Positive EMG/NCS findings, the presence of myofascial bands relating to the plexus seen on MR Neurography, failure of appropriate physical therapy
Surgery No EMG/NCS changes, the presence of myofascial bands seen on MR Neurography, and failure or inability to do physical therapy No MR. Neurography, severe symptoms that fail to respond to all forms of conservative management –These cases have to be individualized
Surgery-Clinical Factors Contraindicating Major depressive disorder unimproved with therapy Limited ability to understand the diagnosis and participate in postoperative and post discharge care A member of a dysfunctional family with no or limited support Comorbid conditions which make surgery difficult or complicate postoperative care
Surgery-Contraindications Severe parascapular dysfunction with significant structural change Severe Complex Regional Pain SyndromeCRPS-2
Conclusions A Biopsychosocial approach will give the physician the diagnosis in the context of the patient and the patient’s struggle with it It will allow the physician to see more clearly the gestaltthe whole picture and assist the patient in understanding and better deal with it