B14. TOS And Cervical Flashcards
What are the mechanisms of injury that cause traumatic brachiplexopathy?
- hyperabduction of the arm causes traction of the brachial plexus
- lateral compression causes traction of the brachial plexus and NR, but plexus more at risk
- slow postural load that traction the brachial plexus
What is the prognosis for brachial plexus injuries?
- usually resolve on their own but recurrent injuries can lead to muscle weakness
How would you differentiate between nerve root lesion and brachial plexus injury
EMG and nerve conduction study
What muscles are weak/paralyzes with an upper trunk (C5-C6) brachioplexopathy?
- shoulder abductors
- elbow flexors
- infraspinatus
NOTE: waiter’s tip posture
What muscles are weak/paralyzes with a middle (C7) trunk brachioplexopathy?
- extensors of the forearm, wrist and fingers
What muscles are weak/paralyzes with a lower trunk (C8-T1) brachioplexopathy?
- wrist and finger flexors
- intrinsic muscle of the hand
NOTE: causes claw hand
What are the sympathetic changes that can accompany a lower trunk brachioplexopathy?
- Edema and trophic changes in the forearm and hand
- Horner’s syndrome
What are the sympathetic changes that can accompany a upper trunk brachioplexopathy?
Horner’s syndrome
What are stingers/burners?
Injuries to nerves in the arm/neck, usually fro contact sports, that cause intense pains that occur when the nerves that run from the neck to the arm are stretched or compressed
What is neurapraxia?
a type of peripheral nerve injury (known as the mildest form of nerve injury) that is classified as a transient conduction block of motor or sensory function without nerve degeneration. It occurs with stingers/burners
What is TOS?
A group of conditions creating arm and sometimes neck symptoms due to entrapment of the neurovascular bundle within the thoracic outlet
What are the common causes of TOS?
- postural
- over use
- trauma
- congenital anomalies
What structures in the thoracic outlet can become entrapped in TOS?`
- brachial plexus
- subclavian artery
- subclavian vein
What are the bony margins of the thoracic inlet/“outlet”?
- T1 vertebrae posteriorly
- Rib 1 laterally
- manubrium and 1st costal cartilage anteriorly
What muscles are doing the compressing in TOS?
- anterior scalene
- pectoralis minor
- subclavian
There are three areas of compromise possible in TOS. What are they? What structures are involved?
- supraclavicular (compression occurs at the interscalene triangle due to anterior scalene and/or cervical rib)
- costoclavicular (compression occurs between first rib and clavicle doe to subclavian muscle, broken clavicle, etc.)
- infraclavicular (compression occurs between the coracoid process and tendon of pec minor usually form hyperabduction injury)
What postural things can contribute to TOS?
- “drooping” shoulder girdle posture
- forward head carriage
- tight pectoralis major
- upper cross syndrome
- poor work ergonomics
- long periods of hyperabduction (sleep posture, recreation, work)
- carrying heavy weights on back or shoulder
What are the three types of TOS?
- non specific
- true neurogenic
- vascular
How common is arterial or venous compression with TOS?
Rare
- 1-2% of TOS have venous compression
- 1-5% of TOS have arterial compression
How is the diagnosis of vascular TOS made?
Constellation of prominent vascular signs and symptoms, NOT loss of pulse during classic TOS orthopedic tests
Which are more valuable indicators of vascular TOS, symptoms or signs?
Signs from the physical are more robust
What are the signs of venous compromise in TOS?
- non-pitting edem
- cyanosis
- ecchymosis
- distended engorgement of superficial veins in infra clavicular area, upper extremity and chest
What are the signs of arterial compromise in TOS?
- pallor in fingertips
- asymmetrical radial pulses
- asymmetrical bilateral blood pressure
- subclavian bruit
- splinter hemorrhages
How common in true neurogenic TOS?
Rare
Who more commonly get true neurogenic TOS?
Young, thin females, possibly with cervical rib
To qualify as true neurogenic TOS, one of two findings must be present. What are they?
- reproducible neurological deficit on physical exam
- positive EMG-NCV study demonstrating plexus damage
What are some of the neurological signs that would be seen in true neurogenic TOS?
- little, no or intermittent pain
- sensory paresthesia or dysesthesia
- symptoms restricted to ulnar aspect of the hand and forearm
- symptoms aggravated by overhead/abducted arm activities
What is Gilliatt-sumner hand?
Dramatic degree of atrophy of the abductor pollicis brevis that may be present with true neurogenic TOS
Interossei and hypothenar eminence may also be atrophied
What are the primary signs of non-specific TOS?
Paresthesia (more common) and pain (less common) in an ulnar distribution (sometimes median) and sometimes in the neck
Who more common gets non-specific TOS?
Women 20-40
What is a physiologic factor that contributes to TOS and occurs with aging?
Progressive acromio-clavicular descent, more pronounced in women
What are some joint restrictions that contribute to TOS?
- first rib
- lower cervical rotation restrictions
What is the recommended group of tests for TOS?
- Adson’s
- Hyperabduction
- costoclavicular
- Roos
- Tinel’s
For 4 out of the 5 recommended orthopedic tests for TOS, a positive test is on a continuum? Describe the continuum.
- strong positive = pain reproduction in upper extremity
- soft positive = paresthesia reproduction in upper extremity
- least positive = loss of pulse (most likely to occur in healthy patients)
Describe how to perform Adson’s test
Patient seated.
Doctor pulls both straight arms back into extension
Patient rotates head away from affected side
Positive test = pain/paresthesia reproduction
Describe how to do hyperabduction (AKA Wright’s) test.
Patient seated.
Doctor abducts one arm at a time
May need to maintain position for 30-60 seconds
Pain reproduction = TOS
Pain improvement = possible NR
Describe the costoclavicular test for TOS.
Patient seated
Doctor pulls both straight arms down and back into extension.
Patient pushed chest out
Positive test = pain/paresthesia reproduction
Describe Roos test
Patient holds arms up
Rapidly opens and closes hands for 3 minutes
Positive sign = arm dropping due to exacerbation of symptoms
Describe Tinel’s and deep pressure test for TOS
Patient seated Doctor taps (Tinel’s) or applies deep pressure just superior to the clavicle
Positive test = pain/paresthesia reproduction
How many of the TOS tests should be positive to make the diagnosis of TOS?
- 2 hard positives (pain reproduction)
OR - 3 hard or soft positives (pain or paresthesia reproduction)
What three key muscles should be assessed with a TOS diagnosis? How would you assess them?
- scalenes (length test)
- pec major (length test)
- pec minor (length test and palpate)
Describe where compression occurs in supraclavicular TOS and what structures are involved
In the scalene triangle
- tight/spasming scalene
- cervical rib
- joint dysfunction of upper ribs or cervical spine
What two orthopedic tests are most likely to be positive with supraclavicular TOS?
Adson’s and Roo’s
Describe where compression occurs in costoclavicular TOS and what structures are involved
The costoclavicular space
- 1st rib
- clavicle (SC and/or AC joint may be involved)
Which of the orthopedic tests would most likely be positive with costoclavicular TOS?
Eden’s test
Describe where compression occurs in infraclavicular TOS and what structures are involved
The space between the coracopectoral structures and the ribs
- tight/spasming pec minor
- AC descent due to aging
Which orthopedic tests are most likely to be positive with intraclavicular TOS?
- Hyperabduction (wright’s)
- Roo’s
TOS has a high incidence of concurrence with what other two conditions?
- carpal tunnel (30%)
- cubital tunnel (10%)
What are your two pain DDX to rule out before diagnosing TOS?
- cervical radicular syndrome
- myofascial pain syndrome (scalene or latissimus dorsi)
What 4 postural categories should be assessed when deciding on a management plan for TOS?
- intrinsic posture (ex: forward head carriage, drooping shoulders)
- extrinsic posture (ex: work station ergonomics, backpacks)
- breathing patterns
- upper cross syndrome
What joints may benefit from CMT in TOS management?
- R1
- C spine
- T spine
- AC
- SC
- GH
- scapulothoracic
How would STM differ for pec major and pec minor in management of TOS?
- pec major would be stretched
- pec minor would do intermittent ischemic compression
What home exercises/treatment could be given in the management of TOS?
- home stretches of scalenes and pectorals
- nerve mobilization
- Brugger relief posture
- diaphragmatic breathing
- endurance exercises for middle/lower traps, external rotators, thoracic extensors, deep cervical flexors
Why is it important to address breathing patterns in the management of TOS?
Vertical/chest breathing may be associated with overactive and tight scalenes
What are some medical interventions for TOS?
- interscalene injection block
- rib resection
- vascular decompression
- sympathetectomy
