Migraine complicated by brachial plexopathy as displayed by MRI and MRA: aberrant subclavian artery and cervical ribs.
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This article describes migraine without aura since childhood in a patient with bilateral cervical ribs. In addition to usual migraine triggers, symptoms were triggered by neck extension and by arm abduction and external rotation; paresthesias and pain preceded migraine triggered by arm and neck movement. Suspected thoracic outlet syndrome was confirmed by high-resolution bilateral magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brachial plexus. An unsuspected aberrant right subclavian artery was compressed within the scalene triangle. The aberrant subclavian artery splayed apart the recurrent laryngeal and vagus nerves, displaced the esophagus anteriorly, and effaced the right stellate ganglia and the C8-T1 nerve roots. Scarring and fibrosis of the left scalene triangle resulted in acute angulation of the neurovascular bundle and diminished blood flow in the subclavian artery and vein. A branch of the left sympathetic ganglia was displaced as it joined the C8-T1 nerve roots. Left scalenectomy and rib resection confirmed the MRI and MRA findings; the scalene triangle contents were decompressed, and migraine symptoms subsequently resolved. (+info)
An unusual case of thoracic outlet syndrome associated with long distance running.
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An amateur marathon runner presented with symptoms of thoracic outlet syndrome after long distance running. He complained of numbness on the C8 and T1 dermatome bilaterally. There were also symptoms of heaviness and discomfort of both upper limbs and shoulder girdles. These symptoms could be relieved temporarily by supporting both upper limbs on a rail or shrugging his shoulders. The symptoms and signs would subside spontaneously on resting. An exercise provocative test and instant relief manoeuvre, which are the main diagnostic tests for this unusual case of "dynamic" thoracic outlet syndrome, were introduced. (+info)
Two-surgeon approach to thoracic outlet syndrome: long-term outcome.
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An orthopaedic surgeon and a vascular surgeon jointly conducted 30 operations for thoracic outlet syndrome in 27 patients, having done the preoperative assessments in conjunction with a neurologist. Anterior scalenectomy was performed by the supraclavicular route except in one case where the infraclavicular route was used. The further surgical procedure was tailored to the abnormalities identified--i.e. resection of cervical rib or band, or medial scalenectomy. The first rib was spared. At median follow-up of 37 months (range 3-228) results were judged excellent or good on 26/30 sides (87%); on the three occasions when scalenectomy alone was performed, the results were only fair or poor. There were no major complications and no patient required reoperation. The long-term outcome in this series suggests that, with multidisciplinary assessment and two-surgeon operative treatment, good results can be obtained by the supraclavicular route without resection of the first rib. (+info)
Surgery for suspected neurogenic thoracic outlet syndromes: a follow up study.
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OBJECTIVES: To assess the outcome of surgical treatment for thoracic outlet syndrome (TOS), and to compare the outcome in patients with and without an underlying cervical rib. METHODS: a heterogeneous group of 40 patients (33 women, seven men; aged 22-62 years) were evaluated 3 months to 20 years after surgery for suspected neurogenic TOS. Forty nine operations had been performed: cervical ribs were removed in 23 patients, together with fibrous band excision in nine. In the 17 without a cervical rib the thoracic outlet was decompressed by resection of the first thoracic rib in nine, and by other operations in eight. RESULTS: After surgery patients reported improved pain (33/36), sensory disturbance (30/35), hand muscle strength (14/27), and hand function (23/34). Postoperatively TOS recurred in two, and symptoms continued to progress in three patients in whom other diagnoses eventually emerged. Surgical complications were recorded in 10 patients, but were transient and did not result in permanent symptomatic sequelae. CONCLUSIONS: Surgical treatment of suspected neurogenic TOS relieves pain and sensory disturbance (90%), but is less effective for muscle weakness (50%). Surprisingly, surgery relieved sensory and motor abnormalities to a similar degree in patients both with and without a cervical rib. Ideally, patients require early operation to forestall permanent hand muscle denervation, but, our retrospective analysis fails to identify any single preoperative diagnostic criterion for TOS, particularly in patients lacking a radiographic cervical rib. (+info)
A wasted hand. Case with uncommon neurological and radiological features caused by a cervical band.
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The symptomatology in the thoracic outlet syndrome is well known. A patient is reported in whom the finding of a unilateral pulse deficit was the alerting sign that led to the correct diagnosis. Angiography, performed with injections during different respiratory phases, visualized the pathogenetic mechanism underlying some of the clinical findings. (+info)
Long-term functional outcome of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients.
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PURPOSE: Neurogenic thoracic outlet syndrome (NTOS) in the absence of bony and electrodiagnostic abnormalities, often referred to as disputed NTOS, remains enigmatic. Optimal treatment, especially the role of surgery, is controversial. The long-term functional outcome of a cohort of patients undergoing independent medical examination for disputed NTOS with symptoms sufficiently severe to cause inability to work forms the basis for this report. METHODS: Patients with disputed NTOS and symptoms sufficiently severe to cause at least temporary inability to work seen for independent medical examinations from 1990-1998 formed the study group. None of the patients were treated by our group. Functional outcome was assessed with information from a standardized telephone interview or patient questionnaire. The patients' ability to return to work and an assessment of their current level of symptoms and symptom progression since the time of onset were determined. RESULTS: Seventy-nine patients were reevaluated at a mean follow-up of 4.2 years (range, 2-7.5 years) after our initial evaluation. Fifteen patients (19%) underwent first rib resection surgery performed by others, whereas 64 (81%) had no surgery. Patients undergoing surgery had missed more work time than those undergoing conservative management (27.6 +/- 6.0 months vs 14.9 +/- 2.6 months, P <.04). Return to work was achieved in nine patients who were operated on (60%) and in 50 patients who were not operated on (78%) (P = not significant [NS]). Among operated patients, current assessment of symptom severity was severe, moderate, mild, and asymptomatic in 7%, 47%, 40% and 7%, respectively. This distribution did not differ significantly from that observed in nonoperated patients (11%, 55%, 30%, 5%; P = NS). When asked about changes in symptomatic status since onset, 7% of the operated group had complete resolution, 27% had marked improvement, 40% had minimal improvement, 13% had no improvement, and 13% were worse. This did not differ significantly from the change in symptoms reported by the nonoperated group (2%, 30%, 22%, 31%, 16%; P = NS). CONCLUSION: Most patients with disputed NTOS in this nonrandomized series were able to return to work and demonstrated an improvement of symptoms with long-term follow-up. First rib resection did not improve functional outcome in this group. (+info)
Management of thoracic outlet syndrome.
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This overall management program for thoracic outlet compression syndrome is based upon experience with 153 extremities in 149 patients and the results of others. The following conclusions are documented and discussed. 1) Diagnosis is based chiefly upon history; physical signs are inconstant and often absent. 2) Major vascular problems are unusual; angiography is not always necessary. 3) Electromyography is not always critical but does aid in diagnosis of carpal tunnel syndrome. 4) Non-operative treatment relieves most patients; operative decompression is indicated for a minority. 5) Transxillary first rib resection, with removal of cervical rib is the best operation. 6) Carpal tunnel decompression should be done concomitantly when needed. 7) Operation is relatively safe. (+info)
Thoracic outlet syndrome caused by first rib hemangioma.
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We report a case of first rib hemangioma that caused thoracic outlet syndrome. A 50-year-ole woman who was admitted to our hospital with a clinical diagnosis of thoracic outlet syndrome presented with fullness and easy fatigue of her right arm. Her right arm discomfort was associated with intermittent engorgement of superficial veins over the shoulder girdle. A chest radiograph revealed an enlargement of the anterior aspect of the first rib with fine bony trabeculations. Computed tomography scan showed contrast enhancement over the enlarged rib. Our tentative preoperative diagnosis was a benign first rib hypertrophic change, such as an old fracture with exuberant callus formation. A right-arm venogram revealed a patent subclavian vein with an extrinsic compression, which occluded on arm abduction. The findings of neural conduction studies of both upper extremities were symmetric and normal. The patient agreed to surgery because of the occlusive condition of the subclavian vein on arm abduction and progressive arm weakness in recent months. Segmental transection of the offending portion of the enlarged first rib was complicated by difficulty in isolating the whole length of the compressed but normal-appearing subclavian vein by our initial transaxillary and infraclavicular approaches because the medial aspect of the subclavian vein was obstructed by the enlarged first rib, which extended medially to the junction of the right jugular and subclavian veins. Successful segmental transection of the enlarged first rib was finally accomplished by combined transaxillary, infraclavicular, and supraclavicular approaches. A moderate amount of rib bleeding from resection ends was noted during segmental resection of the enlarged first rib, resulting in local hematoma formation. A 470-mL bloody discharge was collected from the vacuum ball inserted via the transaxillary route during her 12-day hospitalization. Pathologic examination revealed an intraosseous hemangioma. The patient had a prolonged course to partial recovery of her arm numbness, but signs of venous compression were much improved at 6 months' follow-up. Although hemangioma is benign, its hypervascular nature may cause catastrophic intraoperative bleeding. (+info)