Saturday, March 31, 2012

Thoracic Outlet Syndrome and Personal Injury

Two truly brilliant doctors presented the most delightful and complex presentations about a not uncommon presentation post trauma and post whiplash.  One was a surgeon. One was a physical medicine specialist.  The slides each had were very carefully chosen and much of their presentations was related to the anatomical drawings and other bits they showed visually.
I was taken back to the very best of the anatomy presentations I had as a medical student coupling that with the latest and greatest of grand rounds presentations. Following that were a question and answer series mostly directed by lawyers.
I knew the anatomy and pathology. I knew the diagnosis. I even knew the general information about treatment though was impressed to get the very latest and even the still controversial aspects of cutting edge management. What I wouldn't have got at medical school or in grand rounds was the lawyers questions. How does this condition apply to a patient with a disability claim. What is the claim and counter claim to the presentation.  Now that's where the doctors answers were most interesting.  It was a bit of a snapshot of a trial really and the doctors did a marvellous job of responding and making their responses understandable to all and sundry. No wonder they are considered the best in their field.

Further I've seen 2 cases this last year myself.  I'm going to review both because I thought one specifically was carpal tunnel syndrome but when everything came back negative I suggested we take a wait and see attitude.  I confess I wish I and the fellows family physician had heard both these presentations because I think there is more I can offer thanks to these fine gentlemen.

These are my notes. The Trial Lawyers Association of British Columbia provided a cd with alot of the papers and presentations. There was so much information being presented that with both doctors I only gleaned highlights.  Further a lot more was on the slides and finally I was only selecting out the bits and pieces of these talks that pertained specifically to my concerns. That said, I think sharing them gives a person a glimpse into the wealth of information these two gentleman presented.  I would strongly recommend anyone with similiar concerns contact them.  In sharing these notes I'm as interested in sharing the level of erudition and discussion that goes on at these conferences.

Post Traumatic Thoracic Outlet Syndrome
Soft Tissue Problem
Dr. A.J. Salvian MD - Surgeon and Vascular Surgeon
 Was a University of Manitoba Vascular Surgeon  (note this man has credentials up the yin yang , they went on for pages and then another speaker took over to continue for two weeks further citing all his accomplishments, I've just extracted out of the long list of international achievements this 2 year stint when he did vascular surgery at University of Manitoba. I did this because these are my notes, I did a month rotation in Vascular Surgery at University of Manitoba. I remember falling asleep holding retractors on livers as the vascular surgeon put in a shunt and did aortic bypass surgery.  At the time the Vascular Surgery department was the leading Canadian service and people were flying in from all over the world surgery .  
Someone else might have noted that he was President of the Canadian Society of Vascular Surgery or that he does surgery at Children's and Vancouver hospital or any number of the accolades that can be referenced to him Yet I noted this fact - it's the way of my note taking. )
Thoracic Outlet Syndrome :  types
  1. Arterial
  2. Venous
  3. Nerurologic
Neurogenic (true)
Post Traumatic 
- Disputed
Anterior Scalene Muscle
Brachial Plexus
and Arterial
  • all of them can be compressed
Thoracic Outlet Syndrome 
-Arterial (Major))
Major Arterial (5%)
-Associated with bony abnormality usually
-Aneurysmal dilatation
-distal embolization
  • patients can present with ischemic hand
  • Investigation and see if we can do bypass
Thoracic Outlet Syndrome
  • Venous (5-15%
may or may not be associated with ‘effort thrombosis’
-cyanoused arm, venous distension
-contrast veography
-lytic therapy “mist catheter” TPA (urokinase streptokinase) 6 weeks
Thoracic Outlet Syndrome - Neurogenic
Dr. Cooper Subclavian Artery thrombosis - 1500
  • cervical rib syndrome
  • 1861 Coote Cervical rib resection
  • 1895 Advent of radiography 
  • 1916 -100 cases of cervical rib syndrome reported
  • early 1900’s focus to other structures
  • 1935 Scalenus anticus syndrome
  • 1943 compression between clavicle and first rib 
  • 1956 ‘thoracic outlet syndrome
A number of operations since then
Present with history of trauma
Headache, neck and midscapular pain
Gradual onset of numbness and tingling, pain from should down the arm, forearm and fingers, - upper plexus C5-6 or lower plexes C8T1.  Often at night and overhead use
Cold blue hand
Thoracic Outlet Syndrome
10% spontaneous
Mostly whiplash injury
Early physio makes them worse
The onset of paraesthesia is usually 1-2 months but can be delayed
Activities that increase neck tension, elevation of arms, lifting or pulling bring on symptons
abscence of use, helps
Often unilateral
GP often thinks it’s carpal tunnel syndrome
Neurologist says nerve conduction studies negative
X rays of C spine often negative or mild
Patients are often told they have nothing or mild CTS
Xrays of c spine are negative or mild . May show some straightening
Patients are developing a “spontaneous nerve’ entrapment.
Predisponsing anomalies are very common
  • 4 large ‘cadaver’ studies - anatomic variance between 35 and 60%
bony or soft tisue
External traum, muscucla spasm, hypotonic shoulder muscles, repetitive injury
Brachial plexus
median C5678 t1
Ulnar c8t1 c7
Radial C5678
Dermatones roots
Trauma and Thoracic Outlet syndrome
37% of ‘whiplash injuries ‘  developed brachial plesuxs irritation dr. idle
35 % have anatomic variations
Thoracic Outlet Syndrome
cervical rib syndrome
Congenital fibrous bands and ligamentous structures 37 - 63% 
  • 8 types
  • scaring noticed o
Neck Trauma and Thoracic Outlet Syndrome
  1. direct trauma - fracture of rib or clavicule - can have immediate numbness
True thoracic outlet syndrome - no obvious start - pain, paresthesia
Occipital headaches
Thoracic Outlet symptons
-pain shoulder - pain and tenderness, neck and scalene
headache -occipital 74%
vascular problems
-irritation of autonomics
true arterial symptons
sympathetic symptons
physical exam
-weak grip strenght
supraclavicular tenderness over scalene 
tinel’s sign
stretch of scalene (hands in air) reproduces paresthesia and pain
arterial obliteration - normal but can indicate anatomic variant - bruit
Differential dx
-radicular-cervical spine nerve root compression -disc , osteophyte
-peripheral nerve compression - carpal tunnel or ulnar entrapment syndrome
-direct brachial plexus injury - stretch, traction,
Xray of thoracic outlet
Ctscan of thoracic
Nerve conduction to rule out other conditions
Conservative therapy
-relax scalene
Stretching, abdominal, breathing, 
-avoid heavy lifting
-botox injection
dominant arm - serious disability
Indication of surgery
-failure of medical management
Post MVA - 80% improvement, 10 % no better, 10% no improvement 10% worse
  • follow up showed benefit took 23 months physical and mental 10 months
thoracic outlet syndrome - Jamieson Artical, CJS Vol 39, Nov 4, 1996

Over the lunch break a judge had spoken to the important contribution of the physiatrists to the discussion of soft tissue injury and personal injury suits. This tidbit was of course included by the one introducing Dr. Laidlow. 

Soft Tissue Conference
March 30, 2012
Medically Mediating the Disputed Thoracic Outlet Syndrome
Dr. Duncan Laidlow MD FRCPC (physical medicine)
Thoracic Outlet Syndrome
Vascular - venous or arterial
Neurogenic - 98% - neurogenic
-true neurogenic -rare - wasting in arm and -emg show abnormality in this group, in ulnar distribution
  • disputed - we know it exists but can’t prove it
Lack of accepted diagnostic criteria
Lack of measuring standards
Lack of information on history
Research limitations
2010 Cochrane review - only one study worthy of review 1966 study
-compression - in sub scalene space  (two muscles surrounding brachial plexus) these are prone to damage in whiplash injury
T1 fibers are most prone to injury as lowest 
Most common presentation is numbness of inner arm and ring finger
Anomalies of the Thoracic Outlet
  • Only 10% of bilateral ‘normal’ anatomy 
lack of agreed clinical features
debate about etiology
lack of confirmatory diagnosis procedure
highly debated treatment outcomes
association with psychiatric issues and secondary gain
-inherrent predispostion
-abnormal posture
Upper and lower varieties
  • arm and hand
  • upper neck and some of face
Diagnostic evaluation
Alot of physical examination ‘signs
Most commonly employed
Modified upper limb tension test
  • looking for reproduction of signs and symptons
Adson test
-turn head to sign and palm up
Elevated arm stress test
-arms up
Hyperabduction test
Eden’s test
-shoulders brought forcibly backwards
Downward pull test 
-pulling arm down.
Plain x ray
Anterior Scalene Block
  • helps to decide if surgery will help
Radiculopathy - radiating pain more often, numbness more discrete
Peripheral entrapment neuropathy - just distal fingers
  • if numbness beyond wrist unusual and therefore usually thoracic outlet
Non Operative treatment
  • studies - 65-100 % treatment  (typical 65-80%)
  • but all have all kinds of problems of randomization
Evidence based conservative approach
-avoidance of purely passive measures
-ergonomic adjustments where possible
  • nutritional counselling
  • exercise program - stretching scalene

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