Nerve Disorders Thoracic Outlet Syndrome Information
Thoracic Outlet Syndrome - Information
Among the most common types of nerve entrapment is Thoracic Outlet Syndrome (TOS) causing pain and weakness in the neck, shoulder, arm and hand.
Although all physicians understand the role of the spine problems in causing shoulder and arm pain, there is a great deal of controversy and confusion regarding the diagnosis of thoracic outlet syndrome. Nerve entrapment of the median nerve in the wrist at the carpal tunnel can affect the thumb and next two fingers - carpal tunnel syndrome. Entrapment of the ulnar nerve at the elbow is cubital tunnel syndrome. However between the spine and the elbow there are many nerves, crossing a long course when these nerves become entrapped or injured, the diagnosis may be TOS.
Thoracic outlet syndrome can affect the blood vessels, or the nerves or both. In the past, it has been easy to diagnose TOS affecting thed blood vessels - causing loss of blood flow when the arms are raised. However, diagnostic proof of TOS affecting the nerves has been considered unsatisfactory or very difficult to achieve. Now, the advent of MR Neurography and Open MR guided injections has revolutionized diagnosis and treatment in this field. With these techniques, Dr. Filler at the Institute for Nerve Medicine has shown that TOS can be divided into as many as six different types of nerve entrapment. Each of these can be reliably and confidently identified and new, minimally invasive treatments are now avaiable for each of these.
In the past, the only surgery widely offered for the treatment of TOS was resection of the first rib. This is a very invasive and difficult operation with an extended recovery period and a very significant risk of major injury to blood vessels, nerves or lung during the operation. Dr. Filler has shown that if the inidividual type of TOS affecting a patient is known in advance, then it is usually possible to plan a small, safe minimally invasive surgery to correct the problem - usually on an outpatient basis.
There are many diagnoses and treatments of thoracic outlet syndrome. Please investigate the articles in this section to learn more about individualized cases from the files of Dr. Filler.
Entrapment in Middle Plexus at 1st Rib
Information: Mid Plexus Entrapment Between Clavicle and First Rib
Slideshow: Entrapment of middle plexus at the costo-clavicular passage.
The right side (A) demonstrates an S-shaped course passing under the clavicle and over the first rib, while the brachial plexus elements on the left side (B) travel along a comparatively straight course. This type of entrapment may be best treated by first rib resection.
Read more...Distal Entrapment in the Axilla
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Information: Distal Plexus Syndromes Affecting the Axillary Nerve and Shoulder
Slideshow: Hyperintense axillary nerve (ax) irritation due to differential motion.
A) Adhesion of the distal plexus may result in axillary nerve irritation because of differential motion at the quadrangular space through which it passes after a short distance of travel. Patients often present with failed rotator cuff surgery undertaken for shoulder pain that has been misdiagnosed. The axillary nerve syndrome presents with pain in the axillary nerve distribution over the shoulder joint and deltoid weakness.
B) Shoulder of a 17-year-old tennis instructor with shoulder pain and difficulty positioning his arm for his serve. The axillary nerve (ax) is seen arching out across the neck of the humerus (hu) after branching off the posterior cord (pc) of the brachial plexus at the origin of the radial nerve (rn) (the beaded appearance of the axillary nerve in this 3D projection image is an artifact of the slice spacing).
Read more...
Asymmetry of the Anterior Scalene Muscles
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Information: Asymmetry of the Anterior Scalene Muscles in Scalene Syndrome
Slideshow: T1 axial image demonstrating asymmetry of the anterior scalene muscles.
This T1 axial image demonstrates asymmetry of the anterior scalene muscles. The arrows point to the anterior scalene muscles. The muscle on the right is about 50% larger than the muscle on the left.
This can reflect either hypertrophy (overgrowth) of the muscle on the left or spasm/atrophy of the muscle on the right. This condition can cause pain and weakness in the shoulder, arm and hand. It is most often caused by whiplash in motor vehicle accidents, by trauma to the neck and shoulder, or by excessive carrying or lifting in a "repetitive strain" situation. It also occurs in some athletes who overbuild the muscle by their training routine or weightlifting.
There is loss of fat between the anterior and middle scalene muscles on the left as well suggesting that the pathology is primarily on the left.
If the diagnosis is confirmed, treatment can include injections to relax the muscle as well as surgery to cut or trim the muscle.
Read more...
Scalene Syndrome
Information: MR Neurography for Diagnosis of Proximal Plexus Syndromes
Slideshow: Differentiation of thoracic outlet syndrome into five major categories of proximal and mid-plexus disease based on imaging characteristics.
A) In the normal plexus, the cervical spinal nerves and trunks of the brachial plexus follow a straight trajectory with even spacing.
B) Scalene syndrome is demonstrated by a gentle deformation of the course of the nerve elements and loss of space between them. In patients with pain only there is usually no nerve hyperintensity.
C1) Distortion of the shape of the C7 element (*) associated with a severe TOS case.
C2) A more anterior image plane in the same patient showing both a sharp kink (K) in the course of the lower trunk associated with a fibrous band and nerve hyperintensity (H) consistent with lower trunk motor symptoms.
Read more...
Proximal Entrapment
Information: Thoracic Outlet Syndrome from Fibrous Band on the Lower Trunk of the Brachial Plexus
Slideshow:Image evaluation of thoracic outlet syndrome.
A 52-year-old woman presenting with a two-year history of right 4th and 5th digit pain and negative EMG/NCV of the ulnar nerve at elbow and wrist, who has no cervical disc disease. The preoperative Neurography (Pre-Op) shows a kink distorting the course of the lower trunk of the brachial plexus. The diagram identifies the anatomy and shows a fibrous band extending from the C7 transverse process to the first rib that causes the image finding.
After a supraclavicular approach for resection of the anterior scalene and neurolysis of the lower trunk, the patient experienced complete relief of right hand and arm symptoms, now maintained at nearly two years follow-up. The postoperative and contralateral images from the same patient show the mechanical result of the surgery in restoring normal anatomy.
Read more...
Dr. Aaron G. Filler, MD PhD
Dr. Aaron Filler is the world’s leading expert in treatment of nerve pain. He has revolutionized nerve-pain treatment by inventing several new technologies. One such technology, MR Neurography, enables doctors to use an MRI scanner to examine nerves — previously a difficult-to-impossible tissue to see through MR imaging. Dr. Filler's research in axonal transport is leading to a whole new generation of advanced pain medications. He has developed many new “minimal access” surgery methods that allow him to treat complex nerve problems with small outpatient surgeries. He has also pioneered the use of the Open MRI scanner to do surgeries and other therapies with the ultra-high precision and safety of the magnetic resonance imaging. Click here to learn more. About NerveMed
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