Chapter VI – Diagnostic Tests for TOS

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Table of Contents

Preface
Introduction
The Sonny Burke Story

Chapter I     What is Thoracic Outlet Syndrome? (TOS)
Chapter II     Anatomy
Chapter III The TOS Controversy
Chapter IV History, Cause, and Patient Presentations
Chapter V   Physical Examination Findings
Chapter VI Diagnostic Tests
Chapter VII Standard of Care Approaches – Surgical and Non-Surgical
Chapter VIII Frequently Asked Questions
Chapter IX Case Histories of Patients
Chapter X     The Human Spring Approach to Treatment and Prevention

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Chapter VI

Diagnostic Tests For Thoracic Outlet Syndrome

What are the diagnostic tests for thoracic outlet syndrome?

Thoracic outlet syndrome is commonly misdiagnosed because it can mimic other nerve compression syndromes such as carpal tunnel syndrome, cubital tunnel syndrome or radial nerve compression. Because thoracic outlet imaging or MRI aren’t as helpful in diagnoses and often times an old disc herniation can confuse a doctor into thinking it is not thoracic outlet syndrome when it really is. That is why you really need to understand where where the thoracic outlet obstruction and thoracic outlet compression of the nerves or arteries or both happens.

I would estimate that thoracic outlet syndrome is misdiagnosed by doctors about 80% of the time. I have all the tests listed and explained for thoracic outlet syndrome in this article. It should help you better self-diagnose thoracic outlet syndrome if you don’t think your doctor is on the right track.

Diagnosis is difficult, because there is no gold standard test, so historical tests and physical findings are extremely important and the diagnosis is based on these historical and physical findings which are corroborated by perhaps some diagnostic and imaging testing, nerve conduction, sensory, velocity testing and SSEP tests, if you care to use those. We haven’t had the need to use those tests because we are treating the patients clinically.

When to order diagnostic tests

I like to order diagnostic imaging tests when I’m not getting the results that I’m looking for, rather than order these tests on every patient that walks into the office. I feel that clinically if I can help the patient within the first two weeks, I’m on the road to recovery and there is no need to order these diagnostic tests.

Of course, if I’m not getting the results that I’m looking for, and I may have to dig deeper to find something I’m looking for, that’s when I order these tests. Like I said, there is no gold standard test we’ve been going over and over it again for thoracic outlet syndrome. The clinical judgment has to be used. There are some diagnostic tests such as electrophysiological evaluation, multi-detector CT and 3-D reconstruction, Venography, Magnetic Resonance Angiography, Radiography, Doppler ultrasonography and SSEP potentials.

1. X-ray Examination Radiography:

When you take your x-rays, you’re going to take cervical flat plate films and thoracic, AP lateral films. The first thing we do when we evaluate the patient is to look for the bilateral cervical ribs. You know what? Cervical ribs are in less than 1% of the population. As I mentioned before, we have seen many thousands of cases. A lot of these patients have had x-rays taken as a result of traumas and peripheral nerve type of neuropathy. We are not finding cervical ribs on a lot of patients. I would say that it’s not less than 1%; it’s less than 1/10th of 1% or less. I remember, maybe 1 case of cervical ribs out of the entire array of patients that I have seen in approximately 18 years of practice including 2-4,000 new patients per year. You’re looking at variable heights of the first ribs as well as you’re looking for the intercostals space. The spaces between the ribs should be equal. If there’s a greater space on the right than on the left, then obviously on the right there have been some ribs elevated. Or on the left, some ribs have subluxated inferiorly. You’re looking for the arthritic changes in costal transverse junctions. That’s arthritic change movement as a result of lack of movement or poor movement or aberrant movement in these ribs. You’re looking for military neck, retrolisthesis and degenerative joint disease in the first rib in the sternum as well as in the costal transverse junctions.

Retrolestisis is a common finding in TOS

We’re going to find that this retrolisthesis is found in 80% of the patients. Why? Because like I said, attachment of the scalene muscles is on the anterior portion of the anterior process of C2, C3, C4, C5 and C6 and when you have to hold the head up for a very long period of time what it does is it actually pulls the curvature out of the spine and this is not a very good thing long term.

Also as a result of the malposition of the first rib, you’re going to find degenerative joint disease and the sternal costal junction. In other words, when the first rib loops around to the front, it attaches to the sternum. If you look very carefully, a lot of time you’re going to find a lot of calcium deposits and deformation in the joint. Many people overlook this. It’s been overlooked quite a bit. You’re also going to see degenerative joint disease of the costal transverse of the upper ribs.

Costochondral arthritic changes

Here’s a picture I found in a book discussing how the patient had just gotten out of surgery In fact and had the left cervical rib removed as a result of long standing thoracic outlet syndrome that did not respond to conservative care. And if you look very carefully where the arrows are on the right what I found is that on the cervical rib, the first, second, third and fourth ribs, there is a fairly large amount of calcium deposit that’s on the costal transverse junctions and the costaclavicular junctions you’ll see the darkened areas of the joint space and adjacent to that area you’ll see the calcium deposits, which means that the normal biomechanics have been altered and that is evidence of what I had mentioned before that when the first ribs are elevated, because of those ribs, the intercostals connect the ribs 1, 2, 3 and 4 together that when the first rib elevates, it brings all the other ribs along with it. It does affect locking the costal transverse joints and causing degenerative joint disease in that area.

2. Electrophysiological Test

When to order Electrophysiological Tests Electrophysiological tests from three or four of the literature that I read, said that it was effective in determining thoracic outlet brachial plexus bundle compression. What you have to understand about the brachial plexus is that they distribute themselves superior to inferiorly 5,6,7,8 T-1. The most commonly affected is T-1 because it’s closer to the first rib causes numbness downward to the ulnar distribution.

What I’m finding is the whole arm is numb. However, according to the studies, impairment of the nerve conduction, primarily F-waves were decreased in amplitude in the ulnar and sometimes the median nerve. Obviously, the ulnar nerve is more T-1/C-8 distribution than the median, which represents more of the gamut of the brachial plexus. This could help localize the brachial plexus lesion and may help to rule out segmental systemic neuropathy such as herniated disc in a particular area of the cervical spine.

You’re not going to find this a very effective test if you do not have access to an MRI or have not ordered it yet. We see this impairment after the arms are raised in a provocative position in other words, the F-wave is normal and the patient is in a neutral position when the arm is raised in a provocative position as in Adsons, Hyperabduction Maneuver, Costaclavicular Maneuver, you will see that the symptoms of the F-wave will be diminished

Only for a long-standing anomalies and severe atrophy The most recent studies of these symptoms are related to thoracic outlet syndrome and the electrophysiological test is that this test is only used for a long-standing anomalies and severe atrophy because in the initial phase of this problem, the F-waves are not diminished and you’re not going to find this a very effective test for a recent onset of thoracic outlet syndrome. Therefore, I don’t feel it’s really necessary.

Do I order these tests in my office? No I don’t.

The reason is that because like I said before, I only order the tests when I’m not getting the results. I’ve never really had a problem with thoracic outlet syndrome in my office. I’m getting very good results with it, so there is no need to expose the patient to diagnostic tests which are medically unnecessary. You must document the need for a diagnostic test.

When to order Electrophysiological Tests

A need for a diagnostic test is used to differentially diagnose or determine to a better extent what is wrong with the patient. If I feel that the patient is recovering in the first five or six visits and making progress, I am going to continue with care, it looks like I am on track, and I am not going to order these diagnostic tests. If the patient takes a turn for the worse, or I’m not getting the results I’m looking for, certainly I will order the diagnostic tests to look into it further to determine whether I haven’t seen what I need to see or I need to see something that I can’t seen based upon the orthopedic tests, the history or physical examination I performed. That ‘s obviously protocol for any type of orthopedic, chiropractic or neurological type of practice.

3. Multi-directional CT and 3-dimensional reconstructions

Multi-directional CT and 3-dimensional reconstructions: There has only been one study, which I have seen. It reports to be very promising. I don’t know I haven’t had much time to look into it. There is not much literature on this. I am not going to run out and order multi-directional CT on every patient that walks in my office with tingling in the fingertips. As I mentioned previously, I use these tests sparingly. Doctors use these tests more often on patients – that’s your clinical judgment

4. Venography

One author stated that Venography was the only reliable diagnostic tool to diagnose thoracic outlet syndrome.

5. Doppler ultrasonography

Doppler ultrasonography was another test that was mentioned in a few studies. There was no real discussion of the reliability or sensitivity of this particular test. It was considered as promising.

6. Magnetic Resonance Angiography

Magnetic Resonance Angiography consists of taking an MRI of the patient in the normal position, and then another MRI is taken of the patient in the provocative position. This MRI must be done in an open MRI scanning unit because of the fact that you have to alter the position of the patient’s arms. It cannot be done in a closed MRI scanning unit. That’s something you have to understand. Also, you have to find a radiologist who understands thoracic outlet syndrome, anatomy, biomechanics, as well as being willing to do two MRI’s of the body: one in the provocative position and one in the normal position. This was done by one particular group of practitioners looking for a way of diagnosing with diagnostic imaging the thoracic outlet. I don’t think it should be done routinely in practices.

7. CT Angiography

This is a very interesting test, which I found in the literature that showed a visual of the thinning of subclavian artery as it passed through the intrascalene muscles. It was very nice evidence that this actually occurs.