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THORACIC OUTLET SYNDROME DIAGNOSIS & TREATMENT

at the sub-coracoid space or at the axillary arch, predominantly leads to paraesthesia in the C8,T1 distribution (5). Pain in this distribution may also be evident (5). n Weakness - is usually only seen in well established cases (5). If the inferior trunk or medial cord of the brachial plexus is involved then weakness may be evident in those muscles supplied by peripheral nerves that have a neural fascicular pathway from C8 and T1 nerve roots travelling within the inferior trunk and medial cord of the brachial plexus. Muscles of the hypothenar eminence, interossei and flexor digitorum profundus III and IV have the potential for displaying objective weakness. Functional limitations resulting from these muscle power deficits, such as difficulties with hand writing may be experienced. Severe compromise of the superior trunk of the brachial plexus has been shown to present with symptoms that are akin to Erbs palsy. Muscle power deficits of deltoid, biceps and rotator cuff have been demonstrated (22). This has been seen with the military brace position of extreme chin retraction combined with scapular retraction (22). It was found that this type of presentation occurred frequently when an anatomic variant of the upper roots of the brachial plexus passing through the anterior scalene muscle existed (22). It was thought that the tethering resulting from the neural passageway through the anterior scalene was enhanced by the depression and retraction of the scapulae performed in the military brace position (22). n Wasting - atrophy is usually only seen in well-established cases (5). The classic wasting seen in neurogenic- TOS is wasting of the abductor pollicis brevis and to a lesser extent the interossei and hypothenar muscles (19).

Neurogenic TOS-sympathetic axons If the sympathetic pathways are interrupted the following clinical manifestations may be evident. n Raynauds phenomenon - may be evident in the hand in neurogenic-TOS patients (4). The coldness and pallor seen here is due to an increased activation of the sympathetic nervous system (4). Raynauds-type symptoms may be seen in both neurogenic-TOS and arterial TOS and therefore clinical

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differentiation must be sought by the practitioner. n Horners syndrome - consists of three ipsilateral components: ptosis, miosis and anhydrosis. Ptosis is a 1-2mm dropping of the upper eyelid. Miosis is constriction of the pupil and anhydrosis is a lack of sweating on the affected side (23).

Provocation clinical testing for thoracic outlet syndrome The provocation tests that are described in the medical literature look at either enhancing compression or providing traction to the brachial plexus and/or vascular structures at the various sites previously described. Unfortunately the description of some of these tests vary within the literature and one test may be given different descriptions for its performance by different authors. In addition, a reader may find that one test may have been given two different names. These discrepancies add to the confusion around a relatively straightforward syndrome. Without doubt the practitioner must therefore understand the aim of each provocation test so critical analysis attributed to the importance of each component of the test can be applied. Although the tests cannot be used to confirm a diagnosis of TOS they are a useful part of the whole assessment process. It is not within the confines of this article to describe the various provocation tests.

DIAGNOSIS The final diagnosis needs to be established based on a balance of evidence from the medical history, clinical examination and investigations (7,24,25). It is important to note that the patient may experience symptoms but investigations, for example nerve conduction tests, do not confirm pathology of the neural structures. Negative nerve conduction findings can be explained on the basis that intermittent compromise of the structure, for example, the inferior trunk or medial cord of the brachial plexus, by traction or compression may result in obliteration of the intraneural blood vessels. This leads to impaired oxygenation of the neural structure leading to paraesthesia (26).This metabolic conduction block is rapidly reversible if the compression or traction are relieved (26) and the nerve does

COSTA-

CLAVICULAR LIGAMENT

Figure 5: Costo-clavicular ligament

COSTA-

CLAVICULAR SPACE

SUBCLAVIUS MUSCLE

Figure 6: Costo-clavicular space

SUB-

CORACOID SPACE

Figure 7: Sub-coracoid space

15

©Primal Pictures 2010

©Primal Pictures 2010

©Primal Pictures 2010

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