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Chapter 30, When it is Not Cervical Radiculopathy: Thoracic Outlet Syndrome—A Prospective Study on Diagnosis and Treatment

J. Paul Muizelaar, M.D., Ph.D., and Marike Zwienenberg-Lee, M.D.

Many neurosurgeons see a large number of patients with some type of discomfort in the head, neck, shoulder, arm, or hand, most of which are (presumably) cervical disc problems. When there is good agreement between the history, physical findings, and imaging (MRI in particular), the diagnosis of cervical disc disease is easily made. When this agreement is less than ideal, we usually get an electromyography (EMG), which in many cases is sufficient to confirm cervical radiculopathy or establish another diagnosis. However, when an EMG does not provide too many clues as to the cause of the discomfort, serious consideration must be given to other painful syndromes such as thoracic outlet syndrome (TOS) and some of its variants, occipital or C2 neuralgia, tumors of or affecting the brachial plexus, and orthopedic problems of the shoulder (Table 30.1). Of these, TOS is the most controversial and difficult to diagnose.

Although the neurosurgeons Adson (1–3) and Naffziger (10,11) are well represented as pioneers in the literature on TOS, this condition has received only limited attention in neurosurgical circles. In fact, no original publication in NEUROSURGERY or the Journal of Neurosurgery has addressed the issue of TOS, except for an overview article in NEUROSURGERY (12). At the time of writing of this paper, two additional articles have appeared in Neurosurgery: one general review article and another strictly surgical series comprising 33 patients with a Gilliatt-Sumner hand (7). In one of the neurosurgical handbooks, the heading of TOS in the index only refers to the chapter on EMG where the condition is mentioned as occurring in conjunction with carpal tunnel syndrome (CTS), whereas four pages are devoted to cervical rib syndrome, hyperabduction syndrome, and costoclavicular syndrome, which are all part of TOS (9). In two newer neurosurgical textbooks, together containing over 4,200 pages, one and one half and four pages, respectively, are devoted to TOS (8, 9). Nevertheless, patients with pain in the neck and discomfort in the upper extremity are seen frequently by neurosurgeons. The surgical treatment of herniated cervical discs, CTS, and tardy ulnar neuropathy—all to be considered in the differential diagnosis of TOS—is practically "daily bread" for most neurosurgeons.

The aim of the present paper is to share the personal clinical experience of a single neurosurgeon with a referral practice for TOS with other neurosurgeons. Over a 3-year period, data for this paper were prospectively gathered on all patients referred with a suspected diagnosis of TOS or in whom the author seriously considered TOS in the differential diagnosis.

MORE ON THE LINK AT TOP

http://abstracts.neurosurgeon.org/cg...=all&wm=wrd&t=
these are older but thought I'd post them anyway.

Displaying documents 1-2 of total 2 found.

1. Transaxillary resection of the first rib is a better operation for thoracic outlet syndrome (TOS) than supraclavicular neuropl
AUTHORS: James N Campbell, M.D., Rishi N. Sheth,M.D.(Baltimore, MD); Introduction: Certain patients present with pain in the shoulder area and upper extremity aggravated by postures such as the spear throwing position. Typically these patients have no n...
{2000}
2. MR Neurographic Findings in Diagnosis of Thoracic Outlet Syndrome
AUTHORS: Aaron G. Filler, MD, PhD, J. Patrick Johnson, P. Villablanca, M. Kliot, K. Maravilla, C.E. HayesR.B. LufkinK. FarahaniJ. TrentH. Machleder; Magnetic Resonance Neurograms(1,2,3) are direct nerve images useful in evaluation of cervical radiculopa...
{1997}

UR GOOD TOO!

I was just wanting this info

Any more info on cervicle pain associated with TOS??

I did a search on your words- "cervical pain associated with TOS"
I'm just posting as I find them - so I haven't read everything.

[Thoractic Outlet Syndrome (TOS)

• Mayo clinic performed 120 procedures in 32 year period.

• Roos describes performing over 1400 procedures in less than 15 years!

• Some confusion exists over what constitutes this particular entity.

Surgical Anatomy

• An opening bordered laterally by the 1st rib, medially by the vertebral column and anteriorly by the claviculomanubrial complex. Though often described, the mere presence of an accessory rib does not always lead to TOS. Instead, the basic common anatomical denominator is compression of the neurovascular bundle (subclavian artery and lower brachial plexus) through several narrow spaces by a variety of physiological and anthropomorphic factors.

Narrow Straits Traversed by the Neurovascular Bundle

1) Interscalene triangle

Anteriorly scalene anticus, posteriorly scalene medius, and inferiorly medial border of first rib. Scalene anticus originates from the transverse processes of C3-C6 and inserts into the scalene tubercle. The scalene medius extends from all of the cervical transverse processes to the rough area of the 1st rib behind the subclavian groove. The triangle is narrowly based caudally, with an apex pointing toward the angle of the jaw.

The interscalene hiatus transmits all trunks of the brachial plexus, but only the lower trunk and the subclavian artery are related to the first rib.

2) Costoclavicular triangle

After leaving the interscalene hiatus, the neurovascular bundle immediately enters a second triangular space bounded anteriorly by the middle third of the clavicle and the subclavius, superoanteriorly by the under surface of the clavicle, posterolaterally by the upper border of the scapula and the subscapularis muscle, and posteromedially by the anterolateral border of the first rib. The boundaries of this triangle are movable with movement of the clavicle. The subclavian vein courses in front of the scalene anticus, and enters this triangle in its medial angle. It may be subject to compression or thrombosis.

3) Subcoracoid space

Distally, the neurovascular bundle passes beneath the coracoid process just deep to the pectoralis minor tendon. Here, the bundle is closely related to the stout clavipectoral fascia. This fascia forms a tight ligament travelling from the costomanubrial joint to the coracoid process (costocoracoid ligament). This ligament can compress the neurovascular structures through the subcoracoid space during shoulder abduction.

Predisposing Factors

Anthropomorphic Factors

• Quadruped to biped state.

• Descent of the acromioclavicular apparatus.

• Typical patient with TOS is postpubertal, asthenic female with a slender neck and poorly developed shoulder musculature.

• Not common amongst healthy muscular men.

Postural/dynamic Factors

• Hyperabduction and external rotation of the arm (painting, car repair).

• Wearing shoulder strap to carry heavy object.

• This causes costoclavicular compression and bowing of the axillary artery and the cords in the subcoracoid space.

Traumatic Factors

• In full arm abduction, the humeral head comes forward from the glenoid fossa and may traumatize the axillary vessels and cords of the plexus.


Structural Anomalies of the Thoracic Outlet

1) Anomalous Ribs

• Incidence of cervical ribs on routine thoracic films: 0.002 - 0.5%.

• Anomalous first thoracic ribs also seen as commonly as cervical ribs.

• Patients with anomalous ribs are symptomatic in only 10%.

• Cervical ribs may be familial.

• Left side most often symptomatic for unclear reasons.

• Role of pre- and post-fixation of the brachial plexus:

In the standard plexus (formed from C5-T1) the obliquely coursing cervical roots inhibit full development of the cervical rib anlages below each exit foramen. The first root that comes out horizontal enough to permit subjacent rib development is the C8 root. The first true (thoracic) rib therefore articulates with the 8th vertebral body. In complete prefixation, the relationships between the roots and the developing ribs is exactly analagous to the standard arrangement except for upward shifting of the first true rib by one vertebral body level. There is no neurovascular compromise.

In incomplete prefixation, continued contribution of T1 fibers to the lower trunk demands that the T1 root ascend and acutely hook across the developing C7 rib, thereby preventing complete ossification of its anterior portion, which subsequently becomes a fibrous band.

• Pathogenesis of symptoms with anomalous ribs:

The abnormal rib raises the level of the thoracic outlet. The neurovascular bundle must therefore ascend to a much higher level and then acutely angulate over the rib or its ligament. This becomes a site of chronic, low grade trauma producing neuritis, axonal degeneration and symptoms. The clinically significant portion of a cervical rib is its anterior portion.

The anterior portion of a cervical rib may force the lower trunk and the subclavian artery against the scalene anticus. If the rib is sufficiently long to fuse to the rib below anteriorly, this will invariably reduce the costoclavicular space so that limb movements will repeatedly slam the clavicle against the pinched artery and nerve.



2. Anomalous Fibrous Bands

• May be more common than ribs as cause of TOS.

• Types:

A) Bands originating from a cervical or rudimentary 1st thoracic rib.

• A short anomalous rib may indicate a fibrous ligament from its tip.

• These represent the anterior portion of the rib anlage that has been prevented from ossifying.

• Invariably attached to the medial border of the 1st rib below, and elevate the subclavian artery and lower trunk toward the clavicle.

B) Bands originating from the C7 vertebra.

• An elongated C7 transverse process represents an abortive attempt to form a cervical rib whose cartilaginous anlage subsequently transforms into a fibrous band that inserts on the T1 rib posterior to the scalene tubercle

C) Bands arising from the 1st thoracic rib.

D) Bands associated with the scalene muscles.

• A sharp tendinous expansion continuous with the anteromedial border of the scalene medius passes to the first rib.

• Lifts the neurovascular structures up and forward.

E) Bands associated with Sibson's fascia.

• Sibson's fascia (suprapleural membrane) is a semi-cone shaped sheet of dense connective tissue that forms a tentlike suspension system for the pleural dome.

• The lower trunk may pass behind the strong posterior border which will hook the lower nerve trunk like a knife edge.



3. Anomalous Muscle Insertions

A) Fused scalene anticus and medius insertions (10% humans)

B) Split scalene medius insertions

C) Scalene minimus hypertrophy

D) Subclavius hypertrophy

4. Anomalous Vessels

• Superficial cervical artery (thyrocervical trunk).

5. Malunited Clavicular Fracture and Other Osseous Lesions

• Callus around the pseudoarthrosis narrows the costoclavicular space.





Clinical Features

The diverse anatomical and physiological factors associated with TOS led to the description of a number of syndromes which are of historical interest.

1) Ochsner 1935 - scalene anticus syndrome (+ve Adson test)

2) Falconer 1943 - costoclavicular syndrome

3) Wright 1945 - hyperabduction syndrome

4) Sunderland - cervical rib syndrome

5) Droopy shoulder syndrome (women with long necks)

Neurological Component

Sensory Disturbance

1) The neurological disturbances are due to involvement of C8-T1 fibers. Rarely, the C7 fibers of the middle trunk are involved. Not an upper trunk lesion.

2) Sensory disturbances appear in advance of motor signs.

3) The initial sensory disturbances are almost always subjective (pain, paresthesiae in 95%).

4) NB:

The pain may not respect the C8-T1 dermatomes.

Paresthesiae may be segmental (inner hand and arm).

Symptoms may be preceded or precipitated by trauma.

Symptoms worsened by postural maneuvers.

Objective signs of C8-T1 sensory impairment occur with time.

Motor Disturbance

1) Weak, stiff, clumsy hands.

2) Weakness of the finger flexors and the intrinsics of the hand.

3) Muscle wasting in severe cases.

4) Common pattern is of thenar wasting with preservation of the hypothenar and interossei. A peculiar predilection for wasting of the abductor pollicis brevis and the opponens pollicis to give a characteristic guttering along the lateral aspect of the thenar pad. Flexor pollicis brevis is curiously spared. Therefore, lateral thenar wasting and ulnar sensory loss. This tends to separate TOS from carpal tunnel or ulnar nerve entrapment.

Vasomotor Disturbances and Trophic Changes

• The majority of sympathetic fibers to the upper limb are in the C8-T1 roots with lesser numbers in the C7 root. The sympathetic fibers are well mixed with the somatic fibers by the level of the first rib, so it is rare to see sympathetic changes before sensory or motor changes. Occasionally, however, a purely vasomotor syndrome will be occur.

1) Usually preceded by sensory and motor complaints. Consists of blanching and coldness of the fingers during exposure to cold; purplish red discoloration of the hand and distal forearm when the arm is dependent, and alternate blanching and red discoloration when the patient is upset.

2) Vasomotor symptoms may be independent of arm movement or position.

3) May see smooth, shiny skin with hair loss and curling of the nails.



Vascular Component

Subclavian Artery Injury

• Symptoms are a function of degree of vascular compression.

1) Ischemic pain of the hand, claudication

2) May get arterial thrombus formation and distal emboization (digit necrosis)

3) Rarely, a fusiform aneurysm will form from repeated trauma

Subclavian Vein Thrombosis

• Occurs at site where the vein passes between the costocoracoid ligament anteriorly and the first rib posteriorly.

1) Aching pain in extremity with signs of venous congestion.





Diagnosis

• Suspected in asthenic postpubertal women with long necks with arm pain associated with paresthesia and numbness in ulnar digits and forearm.

• Paradoxical thenar wasting and ulnar sensory loss strongly suggest diagnosis.

• No test is pathognomic for TOS!

• Real differential is between C8-T1 radiculopathy caused by TOS and cervical spondylosis.

Nerve Conduction Studies

1) Low amplitude median motor responses - most consistent

2) Low amplitude ulnar sensory action potentials

3) Relatively low or normal amplitude ulnar motor responses

4) Normal median sensory NCS

EMG

• Abnormalities most severe in the intrinisics of the hand muscles

Stress Tests

1) Pulse obliteration (may be a normal finding in most patients).

2) Ninety degree abduction external rotation test (head turned to opposite side). Probably best and most reliable test.

3) Exaggerated military maneuver: chest thrust.

4) Adson test - deep breath, head turned toward affected side.

5) Hyperabduction test.

Radiography

• Plain films. Anomalous rib or elongated C7 transverse process. Pancoast tumor, callus from fracutre, neurofibroma etc.

• C Spines films.

• Subclavian arteriography and venography.





Management

Conservative

• Avoid postures and movements exacerbating condition. Between 50-90% can be managed conservatively.

Surgery

Absolute Indications

1) threatened ischemia

2) vascular occlusion

3) peripheral emboli

4) progressive neurological deficit, wasting

Approaches

1) Posterior subscapular approach

• Good accessibility, but technically demanding and leaves patients with painful shoulder, and possible winging of the scapula.

2) Anterior subclavicular approach

• Infraclavicular incision. Poor visualization of the nerve trunks and great vessels.

3) Transaxillary approach

• Transverse incision over third rib in axilla.

• Exposes whole first rib without extensive muscle transection, but allows visualization of only the distal neurovascular bundle.

4) Anterior supraclavicular approach.

• Best approach for visualization of entire plexus and thoracic outlet.

Updated 25/01/97] http://www.ucsf.edu/nreview/09.2-Per...cicOutlet.html

Thoracic outlet syndrome: a 50-year experience at Baylor University Medical Center
Harold C. Urschel, Jr., MDcorresponding author and Harry Kourlis, Jr., MD
From the Department of Thoracic and Cardiovascular Surgery, Baylor University Medical Center, Dallas, Texas.

Corresponding author: Harold C. Urschel, Jr., MD, Chair of Cardiovascular and Thoracic Surgical Research, Education, and Clinical Excellence, Baylor University Medical Center, 3600 Gaston Avenue, Suite 1201, Dallas, Texas 75246 (e-mail: drurschel@earthlink.net).
Small right arrow pointing to: See commentary "Invited commentary" on page 135.
Top
>Abstract
{you can click on these topics on the website- good info}
A PERSONAL INTEREST
HISTORICAL NOTE
SURGICAL ANATOMY
NERVE COMPRESSION
DIAGNOSIS
UPPER PLEXUS VS LOWER PLEXUS
ARTERIAL COMPRESSION
SYMPATHETIC NERVE COMPRESSION
SURGICAL APPROACHES FOR DORSAL SYMPATHECTOMY
PSEUDOANGINA
VENOUS COMPRESSION
RECURRENT THORACIC OUTLET SYNDROME
RECURRENT ARTERIAL ABNORMALITIES
MORTALITY AND MORBIDITY RATES
RESULTS
Acknowledgment
References

Abstract
During the past 5 decades, the recognition and management of thoracic outlet syndrome (TOS) have evolved. This article elucidates these changes and improvements in the diagnosis and management of TOS at Baylor University Medical Center. The most remarkable change over the past 50 years is the use of nerve conduction velocity to diagnose and monitor patients with nerve compression. Recognition that procedures such as breast implantation and median sternotomy may produce TOS has been revealing. Prompt thrombolysis followed by surgical venous decompression for Paget-Schroetter syndrome has markedly improved results compared with the conservative anticoagulation approach; thrombolysis and prompt first rib resection is the optimal treatment for most patients with Paget-Schroetter syndrome. Complete first rib extirpation at the initial procedure markedly reduces the incidence of recurrent neurologic symptoms or the need for a second procedure. Chest pain or pseudoangina can be caused by TOS. Dorsal sympathectomy is helpful for patients with sympathetic maintained pain syndrome or causalgia and patients with recurrent TOS symptoms who need a second procedure.

Use the link and go to the site - explore the side tabs on the left.
I skimmed thru it and some nice information there.

http://www.pubmedcentral.nih.gov/art...9872#id2595089

December 2001, 14:6 > Neurogenic Thoracic Outlet Syndrome...


Neurogenic Thoracic Outlet Syndrome in Whiplash Injury.


ORIGINAL ARTICLES
Journal of Spinal Disorders. 14(6):487-493, December 2001.
Kai, Yukihiro; Oyama, Masanobu; Kurose, Shinnosuke; Inadome, Tatsuro; Oketani, Yutaka; Masuda, Yoshitake

Abstract:
Summary: A prospective study of 110 patients was carried out to determine the pathogenic significance of trauma to the upper body in the development of neural compressive irritation at the thoracic outlet. Twenty-nine patients were reviewed as cervical strain injuries (N group), 25 patients as probable neurogenic thoracic outlet syndrome (NTOS) (PT group), 39 patients as definite NTOS (T group), and 17 patients as NTOS associated with cervical disc disease (CD-T group). The time lapse between accident and diagnosis and the duration of treatment were significantly longer in T patients or CD-T patients than those in the N group. Radiography of NTOS patients also showed a higher percentage of cervical spine-length/height ratio. Traumatic NTOS would suggest two types related to direct damage of scalene muscles that included some physical aspects of cervical disc disease. Pathogenesis provided a key to the resolution of more complex posttraumatic problems of whiplash injury.

(C) 2001 Lippincott Williams & Wilkins, Inc.
http://www.jspinaldisorders.com/pt/r...195628!8091!-1

To get full text you have to be a subscribed member.

Victoria might have this already???
{Journal of Spinal Disorders. 14(6):487-493, December 2001.}

An Idaho work injury findings- very interesting - shows how strong and clear evidence is needed to prove a claim. All Drs must have the same info and be told of ALL symptoms every time.
http://www.iic.idaho.gov/legal/decis...-19-2003-f.htm

ah good it all fit here...

Welcome to the Idaho Industrial Commission's website.



BEFORE THE INDUSTRIAL COMMISSION OF THE STATE OF IDAHO



DENISE 2003, )
Claimant, )
)
v. )
)
)
) IC 00-036000
Employer, )
)
and ) FINDINGS OF FACT,
) CONCLUSION OF LAW,
AMERICAN HOME INSURANCE CO., ) AND RECOMMENDATION
)
Surety, ) Filed Sept. 19, 2003
)
Defendants. )
_____________________________)



INTRODUCTION

Pursuant to Idaho Code § 72-506, the Industrial Commission assigned the above-entitled matter to Referee Michael E. Powers who conducted an emergency hearing in Boise, Idaho, on April 22, 2003. Claimant was present and represented by M. Sean Breen of Boise. Natalie Camacho Mendoza, also of Boise, represented Employer/Surety. Oral and documentary evidence was presented. One post-hearing deposition was taken. The parties submitted briefs and this matter came under advisement on August 7, 2003.

ISSUE

By agreement of the parties at hearing, the sole issue to be decided is whether Claimant’s neck condition is causally related to her industrial accident.

CONTENTIONS OF THE PARTIES

Claimant contends that her left-sided neck pain is directly related to her October 22, 2000, industrial injury, that she reported both neck and shoulder pain upon her initial visit to Employer’s designated medical care provider, and that the neck pain continued after her rotator cuff repair.

Defendants concede that Claimant suffered a left shoulder injury on October 22, 2000. They contend, however, that Claimant received reasonable medical care for her shoulder, including surgical repair of a torn rotator cuff and that her complaints of neck pain did not surface until after she was released back to work from her shoulder injury. Defendants argue that there is no causal connection between her October 2000 industrial accident and her current complaints of neck pain.

EVIDENCE CONSIDERED

The record in this matter consists of the following:

1. The testimony of Claimant taken at the hearing;

2. Claimant’s Exhibits 1-9 admitted at the hearing;

3. Defendants’ Exhibits 1-13 admitted at the hearing with the exception of mammography records from June, 2001; and

4. The post-hearing deposition of Dr. Lawrence Richman.

After having considered all the above evidence and the briefs of the parties, the Referee submits the following findings of fact and conclusion of law for review by the Commission.

FINDINGS OF FACT

1. On October 22, 2000, Claimant was employed as a cashier at Employer’s Nampa, Idaho, store. Claimant was injured while loading forty-pound bags of rock salt for a customer. As she was lifting a bag of salt into the customer’s cart, it slipped from her right hand and pinned her left hand, causing pain in her neck and shoulder.

2. Two days later, on October 24th, Claimant assisted management personnel in preparing a written accident report. The accident report described the injury as: "neck pain going into shoulder." Claimant’s Exhibit 1. On the same day, Claimant was referred to JobCare, Employer’s designated medical provider where Charlie Frost, PA-C, saw her. The chart notes entered by PA Frost on that first visit state: "She experiences no paresthesias, neck pain, or headache. . . . She has never had a history of neck pain or trauma or left shoulder pain or trauma." Defendants’ Exhibit 1. Mr. Frost diagnosed left rhomboid and left upper pectoralis major strain, prescribed Naprosyn and Cyclobenzaprine and returned Claimant to work with restrictions.

3. Claimant continued to see PA Frost regularly until December 27, 2000. Chart notes for these subsequent visits either make no mention of neck pain or state that Claimant denies neck pain, headaches, or visual disturbances. At hearing and in her deposition, Claimant remained firm in her assertion that she complained of neck pain during these visits and was repeatedly advised that the pain was in her shoulder radiating to her neck and that when her shoulder resolved, the neck pain would resolve as well. While Claimant treated with PA Frost, he kept her on restricted work duty. PA Frost referred Claimant to physical therapy on November 7, 2000. She continued with therapy through December 1, 2000.

4. On her December 5, 2000, visit to JobCare, PA Frost detected signs of impingement in the left shoulder and ordered an MRI, which was conducted on the same day. The MRI was negative for rotator cuff tear.

5. Claimant returned to JobCare for a regular follow-up with PA Frost on December 27, 2000. PA Frost was away, and Claimant was seen, for the first time since her injury, by a physician, Douglas M. Hill, M.D. Dr. Hill noted that Claimant had been taking anti-inflammatories, was on restricted work duty, had undergone physical therapy, and an MRI, all with no evident improvement to her shoulder. He recommended a course of chiropractic care with Dr. King, which Surety denied. Dr. Hill prescribed Vioxx in addition to the ibuprofen Claimant had been taking and kept her on work restrictions.

6. Claimant returned to JobCare on January 9, 2001, a day before her scheduled appointment because she was experiencing significant discomfort in her shoulder and neck. She was seen by Dr. L. Sladich. Dr. Sladich gave Claimant Darvocet and Flexeril, suggested a steroidal injection, and continued her work restrictions. When Claimant returned the following day for her scheduled appointment with Dr. Hill, he referred her to Jeffrey G. Hessing, M.D., an orthopedic specialist.

7. Dr. Hessing saw Claimant on January 26, 2001. He opined that Claimant sustained a partial tear of her left rotator cuff as a result of the October 2000 industrial accident. X-rays taken during the examination failed to show any bony pathology in the shoulder that would account for Claimant’s complaints. Dr. Hessing gave Claimant an injection with Celestone and Xylocaine, advised her to continue with her rotator cuff exercises, continue her work restrictions, and to check back in two weeks.

8. Claimant returned to Dr. Hessing on February 14, 2001. She reported only short-term relief from the shoulder injection. Dr. Hessing again opined that Claimant had rotator cuff impingement and noted that conservative treatment had obviously provided no relief. He recommended arthroscopic evaluation with decompression and distal claviculectomy as indicated. Arthroscopic surgery on Claimant’s left shoulder was performed on March 23, 2001. The post-operative diagnosis was left shoulder impingement syndrome with hypertrophic change to the acromioclavicular joint. Dr. Hessing performed a subacromial decompression and distal claviculectomy.

9. Claimant’s post-operative recovery was initially unremarkable. By May 22, 2001, Claimant had, with the assistance of physical therapy, achieved 160 degrees of flexion and 125 degrees of abduction with the affected shoulder. Post-operative x-rays showed normal bones and joints in Claimant’s shoulder. Dr. Hessing released Claimant to modified duty effective May 28, 2001. By June 6th, however, Claimant was complaining about muscle spasm in her shoulder and neck, and her abduction was limited by pain to 100 degrees. Dr. Hessing noted no swelling or crepitus about the shoulder. Dr. Hessing opined that the Claimant needed to be pushed along, and recommended that she be weaned from the physical therapy and transitioned to home exercise. He directed that she continue her present light duty work. Dr. Hessing saw Claimant again on July 3th. At that time he noted that Claimant’s physical therapist had documented 150 degrees of active assisted flexion in the affected shoulder. Claimant continued to complain of pain, and advised Dr. Hessing that she was looking for a job change and documentation of disability. Dr. Hessing refused to provide an impairment rating, and noted that he believed Claimant was "just not taking this opportunity to get better." Defendants’ Exhibit 4. He did prescribe some anti-inflammatory, and advised her to continue her light duty. Dr. Hessing advised the Surety that Claimant wanted another evaluation of her shoulder and that he could do nothing more for her.

10. On September 6, 2001, Claimant saw Paul C. Collins, M.D., who on examination found her shoulder to be stable. X-rays of the shoulder were negative and Dr. Collins opined that Dr. Hessing’s April decompression had been adequate. Dr. Collins reviewed an earlier MRI, but due to the quality of the film was unable to read it adequately. He suggested Claimant have another MRI which she did on September 11. The MRI showed supraspinatus tendinosis, some fraying but no tear in the rotator cuff, and no evidence of a recurrent impingement. Dr. Collins noted that Claimant’s primary complaints were related to her neck, not her shoulder, and diagnosed a left shoulder and cervical spine strain. He prescribed a cervical collar and physical therapy to rehabilitate her neck. On October 1st, Dr. Collins advised the Surety that he believed Claimant was at maximum medical improvement for her shoulder and gave her a 5% permanent partial impairment of the left arm at the shoulder. With regard to her neck complaints, Dr. Collins advised the Surety that Claimant’s range of motion was better even though she had not yet started physical therapy. He emphasized the importance of the physical therapy and stated that he believed Claimant’s cervical complaints would resolve within six weeks with no permanent impairment. He released her to full duty effective November 15, 2001.

11. Claimant returned to Dr. Collins on December 5, 2001, complaining of intense neck pain. Dr. Collins recommended an MRI of Claimant’s cervical spine to rule out anatomical causes and placed her on light duty pending the MRI results. The MRI was conducted on December 7. It showed a central disk herniation at C2-3 that neither contacted nor deformed the spinal cord. The films showed "diffuse marrow edema throughout the C6 vertebral body," suggesting the possibility of an occult fracture at C6. In light of these findings, Dr. Collins ordered a CT scan of Claimant’s C6 vertebral body. The results were negative.

12. On January 17, 2002, Claimant saw Howard A. King, M.D., on referral from Dr. Collins. At the time of her visit, Claimant continued to complain of neck pain. In addition, she advised Dr. King that she was having headaches, and that she and her husband had noticed a left facial droop. On examination, Dr. King identified some facial asymmetry and noted that Claimant demonstrated good flexion, extension, and rotation of her neck and upper extremities. He expressed concern about the headaches and facial droop and recommended a bone scan, taking Claimant off work entirely until the bone scan was completed. Dr. King also recommended that Claimant see Allen C. Han, M.D., a neurologist. Surety did not authorize the bone scan. Claimant continued to see Dr. Collins through October 2002 when he released her without restrictions for her shoulder. She continued treating with Dr. King after her referral to Dr. Han.

13. Claimant first saw Dr. Han on or about April 1, 2002. During that visit, Claimant was complaining, among other things, of neck pain, left-sided headaches accompanied by nausea and vomiting, muscle spasm in the neck and shoulders, numbness on the left side of the face and in the left arm, and weakness in the left arm. Dr. Han did not have the results of the cervical spine MRI at the time of the exam and relied upon Claimant’s report that she had two herniated disks and a cervical fracture in making his assessments and recommendations. He identified the headaches as migraines and suggested an EMG of the left upper extremity. The EMG showed a mild left ulnar neuropathy at the elbow and some possible cervical radiculopathy in the vicinity of C6-7. When she returned on July 2, Dr. Han performed trigger point injections in the left trapezius muscle and prescribed physical therapy. When Claimant returned on August 27, 2002, she reported no significant relief from the trigger point injections. She had not started physical therapy because Surety had not authorized it. Since her previous visit to Dr. Han she had made several trips to the emergency room for severe headaches. Dr. Han diagnosed chemical depression and started her on a course of prescriptions for the migraines. Dr. Han attributed Claimant’s left-sided neck muscle spasm and pain directly to her on the job injury of October 22, 2000. He opined that the left-sided headaches with migrainous features and her chemical depression were indirectly related to her on-the-job-injury. Claimant did not return to see Dr. Han until January 2003.

14. Claimant saw Dr. King on December 17, 2002. Once again he requested a bone scan. The requested scan was performed on January 2. It was negative. Claimant saw Dr. Han on January 15, 2003. He requested a head MRI to rule out structural abnormalities causing the facial spasm and a cervical spine MRI to rule out spinal cord and nerve root abnormalities. The MRIs were performed on January 27, 2003.

15. Claimant saw Dr. Han on February 7, 2003. His chart notes indicate that he discussed the MRI results with Claimant. The head MRI was, for the purposes of this proceeding, unremarkable. The cervical MRI revealed an Arnold-Chiari type 1 malformation and was suspicious for vertebral hemangioma at C6, C7, and T3. He referred Claimant to a neurosurgeon for evaluation of the Arnold-Chiari type I malformation. Claimant saw Dr. King on February 21, 2003. He, too, recommended a neurosurgical consult with regard to the Arnold-Chiari malformation, and in addition, placed Claimant on no-work status. Dr. King opined, however, that he did not believe the Arnold-Chiari type 1 malformation was the result of the industrial injury in October 2000. This is the last documented visit to Dr. King in the record.

16. Claimant saw Dr. Han again on March 21, 2003. He noted that Claimant had not seen a neurosurgeon, as Surety had not authorized the referral. Dr. Han then opined:

Allen’s maneuver is positive with decreased radial pulse and positive bruit over the supraclavicular fossa ipsilaterally, in both upper extremities. Therefore, I suspect [Claimant] most likely has bilateral thoracic outlet syndrome, asymptomatic on the right and symptomatic on the left. I believe that this is ultimately related to her on the job injury in 2001.

Defendants’ Exhibit 10. This is the last documented visit to Dr. Han in the record.

17. On April 17, 2003, at the request of Defendants, Claimant underwent a neurologic consultation and medical exam by Lawrence M. Richman, M.D., in Los Angeles, California. Dr. Richman’s report, Complex Neurologic Consultation/Qualified Medical Exam, was issued April 17, 2003. Dr. Richman has an extensive curriculum vita and is board certified in neurology and electrodiagnostic medicine. Dr. Richman’s experience also includes a number of years of teaching. At the time of his involvement in this case, he taught both residents and medical students in the neurology clinic at Cedars-Sinai Medical Center.

18. Dr. Richman offered his opinion on three primary issues related to Claimant’s condition. These included Dr. Han’s diagnosis of thoracic outlet syndrome (TOS), the Arnold-Chiari type 1 malformation, and the cervical spine changes noted at C2-3.

19. Dr. Richman opined that Claimant showed no evidence, either historically, or on his exam, of TOS. Dr. Richman noted the extreme rarity of the condition, the inappropriate use of the Allen’s test as a diagnostic tool by Dr. Han, and Claimant’s notable lack of symptomotology. In particular, Dr. Richman noted that patients with true neurogenic TOS would have objective findings of C8-T1 or lower trunk neural compromise including loss of sensation in the ulnar and/or medial brachial – antebrachial nerves, muscle wasting (particularly muscles innervated by the median nerve) and EMG results consistent with a C8-T1 root or lower trunk lesion.

20. Dr. Richman opined that Claimant did, in fact, have an Arnold-Chiari type 1 malformation. He noted, however, that this condition is congenital and therefore not caused by the industrial accident. He further opined that Claimant’s Arnold-Chiari malformation had always been and remained asymptomatic. A literature search conducted by Dr. Richman provided no suggestion that an Arnold-Chiari type 1 malformation could in any way be exacerbated or aggravated by the type of industrial injury that Claimant sustained.

21. With regard to Claimant’s complaints of cervical spine pain, Dr. Richman observed that the medical records contained striking inconsistencies. In particular, he noted that the report on the cervical spine MRI conducted on December 7, 2001, discussed an extruded disk at C2-3 with no contact between the spinal cord and nerve root but did not mention the Arnold-Chiari malformation. A CAT scan of the cervical spine performed on January 14, 2002, was normal and showed no evidence of cervical disk disease. The cervical spine MRI performed January 27, 2003, showed the Arnold-Chiari malformation but no cervical disk disease. Dr. Richman suggested that these inconsistencies might warrant further diagnostic work-up to confirm or rule-out cervical disk disease. He was clear, however, that even if cervical disk disease was confirmed, it was not related to her industrial accident, but was degenerative in origin.

22. Dr. Richman also noted in his report that he had confirmed Dr. Han’s diagnosis of a mild ulnar entrapment of the left elbow. He opined that this was likely a repetitive motion injury resulting from Claimant’s work as a cashier that was aggravated and made symptomatic by the industrial injury. Dr. Richman also noted that he found no evidence of facial droop as reported by Claimant, that her headaches were migraines, and that there was a likely connection between her pain complaints, her migraines, and her diagnosed depression.

DISCUSSION AND FURTHER FINDINGS

23. Causation. There is no dispute that on October 22, 2000, Claimant sustained a work-related injury to her left shoulder. Following a lengthy course of conservative treatment, Claimant underwent a subacromial decompression and distal claviculectomy on March 23, 2001. She was released to full duty on November 15, 2001. Dr. Collins gave Claimant a 5% PPI of the left arm at the shoulder. What is at issue at this time is whether that accident caused the neck pain of which Claimant now complains and for which she now seeks benefits.

24. Burden of proof. The burden of proof in an industrial accident case is on the claimant.

The claimant carries the burden of proof that to a reasonable degree of medical probability the injury for which benefits are claimed is causally related to an accident occurring in the course of employment. Proof of a possible causal link is insufficient to satisfy the burden. The issue of causation must be proved by expert medical testimony.

Hart v. Kaman Bearing & Supply, 130 Idaho 296, 299, 939 P.2d 1375, 1378 (1997) (internal citations omitted). "In this regard, 'probable' is defined as 'having more evidence for than against.'" Soto v. J. R. Simplot, 126 Idaho 536, 540, 887 P.2d 1043, 1047 (1994). Applying the law to the facts in this case it is more probable than not that Claimant sustained an injury to her neck at the time of the industrial accident. Claimant reported both neck and shoulder pain in her initial report of injury. She was firm, and credible, in her testimony that she repeatedly told her caregivers that the pain was in her neck and shoulder. While no one can be certain why Claimant’s complaints were not reflected in the chart notes, Claimant consistently and believably stated that when she complained about her neck she was repeatedly told the pain was really in her shoulder. Clearly the focus of her treatment was initially on her shoulder. It was not until her recovery from her shoulder surgery was nearly complete that her doctors began paying attention to her complaints of neck pain.

A careful review of the record in this matter suggests that there is general agreement among the medical professionals that Claimant did sustain a soft tissue neck injury at the time of her industrial accident in October 2000. Dr. Collins diagnosed Claimant with a cervical spine strain as early as September 2001. His October 1, 2001, letter to Defendant Surety implies that Claimant’s neck complaints at that time were related to the industrial accident. One year later, in his September 29, 2002, letter to Surety, Dr. Han opined that Claimant’s left-sided muscle spasm and pain were directly related to her industrial injury. In his deposition, Dr. Richman expressed his agreement with Dr. Han’s opinion on this matter. The Referee finds that Claimant suffered a soft tissue neck injury or cervical strain as a result of her industrial accident on October 22, 2000. Such a finding, however, is not dispositive.

25. In late 2002 and early 2003, Claimant was still complaining of neck pain. According to Dr. Richman, this lengthy period of recovery was far beyond the time one would expect for a soft-tissue injury like Claimant’s. In his deposition, on redirect, Dr. Richman was asked about the recovery period for a neck strain. His response:

There are some people that believe soft tissues [sic] injuries resolve within a few weeks. There’s some published literature, at least with respect to the back, that say one month. Some people say two months.

I tend to be on the more generous side – though some people may not consider that generous – to be three months. In this particular case I doubled that to six months. So taking everything into account, I believe that six months is probably three times the allotted time for most soft tissue injuries to resolve.

I think that’s fairly, we’ll say, extensive. And again, this was not a whiplash in a motor vehicle at 20, 30 miles an hour whiplash. This was a lifting incident. So I truly believe that six months is more than ample.

Dr. Richman's Deposition, p. 74. By February of 2003 Claimant had undergone a number of imaging studies of her cervical spine, including MRI, CAT and bone scans and x-rays in an effort to identify the cause of her persistent neck pain.

Arnold-Chiari Type 1 Malformation. As a result of the imaging done on Claimant’s cervical spine, she was diagnosed with Arnold-Chiari type 1 malformation. As discussed earlier, this is a congenital condition where the cerebellar tonsils extend into the cervical spinal canal. As occurred in Claimant’s case, this type of Chiari malformation is usually asymptomatic and discovered in adults as a result of testing for other conditions. The only medical evidence in the record that discusses Arnold-Chiari type 1 malformation as it relates to this particular case is the report and deposition of Dr. Richman. Dr. Richman’s opinion, supported by the literature and uncontroverted in the record, is that Claimant’s Arnold-Chiari malformation is unrelated to the industrial accident. Since the condition is congenital, it was not caused by the industrial accident and there is no evidence to suggest that the condition could become symptomatic as a result of the type of industrial injury Claimant sustained. The Referee finds that Claimant’s Arnold-Chiari type 1 malformation was in no way caused by or exacerbated by her industrial injury.

Cervical Disk Issues. As discussed in the Findings of Fact, imaging of Claimant’s cervical spine was inconclusive as to whether or not Claimant has cervical disk disease that might be causing her pain. Several of Claimant’s medical providers discuss the possibility of cervical disk disease as a cause for Claimant’s neck pain. Without a firm diagnosis of C2-3 disk pathology, attributing the pathology to the industrial accident is speculative at best. Even if Claimant does have cervical disk disease, there is insufficient evidence in the record to relate it to the industrial accident. Dr. Richman opined that even if one assumes the Claimant has cervical disk disease, it is likely to be degenerative, not traumatic.

Thoracic Outlet Syndrome. Dr. Han, in his March 21, 2003, visit with Claimant, posited a diagnosis of bilateral TOS as a cause of Claimant’s persistent neck pain. Further, Dr. Han opined that Claimant’s TOS was the result of her industrial accident. In support of this diagnosis, Dr. Han noted a positive Allen’s maneuver with decreased radial pulse and positive bruit over the supraclavicular fossa ipsilaterally in both upper extremities. Dr. Han opines that Claimant’s TOS is asymptomatic on the right and symptomatic on the left. Dr. Richman characterizes Dr. Han’s diagnosis of TOS as "tenuous." As reasons for disputing Dr. Han’s diagnosis, Dr. Richman notes that the Allen’s maneuver is not an appropriate test for identifying neurological disease, that TOS is extremely rare unilaterally and even more so bilaterally, and that Claimant has none of the symptoms associated with TOS including atrophy of the thenar muscles, atrophy of the ulnar muscles and radiological evidence of a prominent C7 transverse process or a true cervical rib. The Referee finds Dr. Richman’s opinion that Claimant does not have TOS to be more credible than Dr. Han’s opinion that she does. Dr. Richman has particularized knowledge regarding the symptomatology and diagnosis of TOS, and his opinions are supported by the medical literature. Dr. Han based his diagnosis on a test (Allen’s test) that is inappropriate for identifying neurologic deficiencies and identified no other symptoms that would support the diagnosis. The Referee finds, based on the record, that Claimant’s persistent neck pain cannot be attributed to a diagnosis of TOS.

26. Claimant has failed to meet her burden of proof that the neck pain she complains of in this proceeding is related, more probably than not, to her October 22, 2000, industrial injury. It is likely that Claimant did sustain a cervical strain from the same accident that caused her shoulder problem. It is uncontroverted in the record that a soft-tissue injury like a cervical strain would have been resolved within six months of the date of injury. The record in this proceeding fails to identify with any degree of probability a medical cause for Claimant’s persistent neck pain, much less a determination that it was caused, more probably than not, by the industrial injury.

CONCLUSION OF LAW

1. Claimant has failed to show that the symptoms for which she seeks benefits were more likely than not caused by the October 22, 2000, accident.



RECOMMENDATION

The Referee recommends that the Commission adopt the foregoing findings of fact and conclusion of law and issue an appropriate final order.

DATED this _16th__ day of September, 2003.

INDUSTRIAL COMMISSION



_/s/______________________________

Michael E. Powers, Referee

ATTEST:

_/s/__________________________

Assistant Commission Secretary

Idaho Industrial Commission. Return to home page.

For comments or questions contact Steve Raeder.

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Pain Practice
Pain Practice

Volume 1 Issue 1 Page 21-35, March 2001

To cite this article: Phillip S. Sizer Jr. MEd, PT, Valerie Phelps PT, Jean Michel Brismee MS, PT (2001)

Differential Diagnosis of Local Cervical Syndrome versus Cervical Brachial Syndrome
Pain Practice 1 (1), 21–35.

doi:10.1046/j.1533-2500.2001.01004.x

Abstract
Differential Diagnosis of Local Cervical Syndrome versus Cervical Brachial Syndrome

* Phillip S. Sizer, Jr., MEd, PT;
* Valerie Phelps, PT;
* Jean Michel Brismee, MS, PT

*
School of Allied Health, Texas Tech University Health Sciences Center, Lubbock, Texas

Address correspondence and reprint requests to: Phillip S. Sizer Jr, MEd, PT, Texas Tech University Health Science Center, School of Allied Health, Physical Therapy Program, 3601 4th Street, Lubbock, Texas 79430. U.S.A.
This article is cited by:

* Phillip S. Sizer Jr, PhD, PT, OCS, FAAOMPT; Valerie Phelps, PT, OCS, FAAOMPT; Esteban Azevedo, MPT, COMT, CSCS; Amy Haye, MPT, COMT; Megan Vaught, MPT, OCS. (2005) Diagnosis and Management of Cervicogenic Headache. Pain Practice 5:3, 255–274
Abstract Abstract and References Full Text Article Full Article PDF
* Phillip S. Sizer Jr, PhD, PT; Keith Poorbaugh, MPT; Valerie Phelps, PT. (2004) Whiplash Associated Disorders: Pathomechanics, Diagnosis, and Management. Pain Practice 4:3, 249–266
Abstract Abstract and References Full Text Article Full Article PDF
* Phillip S. Sizer Jr. MEd PT PhD(c),; Valerie Phelps PT; Greg Dedrick MPT; Omer Matthijs PT. (2002) Differential Diagnosis and Management of Spinal Nerve Root-related Pain. Pain Practice 2:2, 98–121
Abstract Abstract and References Full Text Article Full Article PDF



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Thoracic outlet syndrome due to hyperextension-hyperflexion cervical injury
Book Series Acta Neurochirurgica Supplements
Volume Volume 97
Book Advanced Peripheral Nerve Surgery and Minimal Invasive Spinal Surgery
Publisher Springer Vienna
DOI 10.1007/b139101
Copyright 2005
ISBN 978-3-211-23368-9 (Print) 978-3-211-27458-3 (Online)
Part Part I:
DOI 10.1007/3-211-27458-8_5
Pages 21-24
Subject Collection Medicine
SpringerLink Date Friday, June 23, 2006

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Acta Neurochirurgica
Advanced Peripheral Nerve Surgery and Minimal Invasive Spinal Surgery
10.1007/3-211-27458-8_5
H.-J. Steiger, Alberto Alexandre, Albino Bricolo and Hanno Millesi
5. Thoracic outlet syndrome due to hyperextension-hyperflexion cervical injury

Alberto Alexandre4 Contact Information, L. Corò4, A. Azuelos4 and M. Pellone4
(4) EU.N.I. European Neurosurgical Institute, Treviso, Italy
(5) EU.N.I. European Neurosurgical Institute, Via Ghirada 2, 31100 Treviso, Italy
Summary
Posttraumatic brachial plexus entrapment in fibrotic scarring tissue is taken into consideration as the cause of complaints for patients who suffered a hyperextension-hyperflexion cervical injury. All 54 patients included in this analysis where symptom-free before the accident and subsequently complained for pain, paresthesia and slight weakness in the arm. In 14 neurological signs of brachial plexus entrapment were observed. Electroneurophysiological, summary index testing was positive for a brachial plexus involvement in all cases. Conservative measures, comprising physical therapy and vasoactive drugs were applied for a period of 6 to 12 (mean 8.4) months; surgical procedure of neurolysis was then proposed in 39 cases to solve the problem. Thirty-two patients were operated on. Twenty of these had a neat improvement on a 6-month to 1-year follow-up. Seven patients had refused surgery; of these 6 patients had clinical worsening at the same follow-up period while 1 remained unchanged. All patients with clinical symptoms not reversed after some time post-injury should be investigated for a possible brachial plexus entrapment.

Keywords Brachail plexus - entrapment - thoracic outlet - hyper-flexion - hyperextension - whiplash injury

http://www.springerlink.com/content/j1204042u0755433/