Thoracic Outlet Syndrome

Question 1

Trunks of the Brachial Plexus

Answer 1

• Upper: C5 and C6
• Middle: C7
• Lower: C8 and T1

Question 2

Cords of the Brachial Plexus

Answer 2

• Posterior: C5, C6, C7, C8, T1
• Lateral: C5, C6, C7
• Medial: C8 and T1

Question 3

Impingement prior to peripheral nerve branches in the cervical spine foramina degeneration

Answer 3

• roots are not mixed until they exit the foramina
• dorsal root is in close proximity to facet joint
• ventral root is in close proximity to uncovertsebral joint

Question 4

Key symptoms of cervical spine impingement foramina degeneration

Answer 4

• dermatomal pattern
• can just be sensory without motor component
• reproduced with closure of foramina

Question 5

Impingement of cervical spine at disc

Answer 5

• bulge/prolapse tend to cause mechanical inflammation & chemical inflammation (acute) to occupy significant space

Question 6

Key symptoms of cervical spine impingement at disc

Answer 6

• dermatomal pattern usually limited to 1
• usually a pattern across neurological tests (sensory, motor, & reflexes)
• foramina closure can reproduce symptoms but repetitive opening may increase symptoms

Question 7

Thoracic outlet syndrome

Answer 7

• entities within the supraclavicular area that can contribute to the symptoms of neuromuscular compression

Question 8

Etiology, Anatomy, & Symptomology of thoracic outlet syndrome

Answer 8

• anatomical structures compressing the brachial plexus
• thoracic outlet: brachial plexus, anterior & medial scalene, clavicle
• nerve root irritation & damage = referred pain

Question 9

Anatomical spaces in the thoracic outlet

Answer 9

• sternocostovertebral space
• scalene triangle
• costoclavicular space
• pectoralis minor space

Question 10

Describe the sternocostovertebral space

Answer 10

• roots have just left the spine & trunks have not formed
• Pancoast tumor

Question 11

Describe impingement at the scalenes

Answer 11

• usually roots pass all the way through scalenes but trunks may start to form on distal edge
• C5, C6 sit close together because they are upper trunk
• C7 sits alone regardless
• C8 tends to join T1 outside anterior scalene to form lower trunk

Question 12

Key symptoms of impingement in the scalenes

Answer 12

• thoracic outlet tests (Adson’s sign)
• if just neurogenic thoracic outlet syndrome (95%): sensory is positive along dermatomal pattern
• typically it is C5, C6 that are impinged unless you have a large rudimentary cervical rib attached to C7 (C8)

Question 13

Describe Adson’s test

Answer 13

• find the patient’s radial pulse in neutral then extend the arm while feeling the radial pulse
• patient can look towards or look away from extended arm
• positive = lose of pulse

Question 14

Erb’s Palsy

Answer 14

• severe C5 and C6
• tearing of the brachial plexus during childbirth

Question 15

Key symptoms of costoclavicular syndrome

Answer 15

• posterior, lateral, & medial cord sensory and motor patterns
• special tests: costoclavicular maneuver (60s, lift arm above head & hyperabduct horizontally for Sx), Roos (60s-3min, open & close hands with hands above head)

Question 16

Pathology in costoclavicular space

Answer 16

• soldiers with heavy backpacks
• test exaggerated military posture with inspiration
• scapular retraction with shoulder ABD clavicle pushes neuromuscular bundle against scalene medius muscle

Question 17

Brachial plexus branches

Answer 17

• in the armpit
• Posterior cord branches: STAR- sub scapular, thoracodorsal, axillary, radial
• Lateral cord branches: LLM (Lucy Loves Me)- lateral pectoral, lateral root of median, musculocutaneous
• Medial cord branches: MMMUM (Most Medical Men Use Morphine)- medial pectoral, medial cutaneous nerve of arm, medial cutaneous nerve of forearm, ulnar, medial root of median nerve

Question 18

What passes through pectoralis minor

Answer 18

• cords
• peripheral nerves

Question 19

Possible symptoms from stretching pectoralis minor

Answer 19

• Lateral: C5-C7 (LLM)
• Medial: C8-T1 (MMMUM)
• Posterior: C5-T1 (STAR)
• Peripheral nerve symptoms

Question 20

Causative pathology within pectoralis minor space

Answer 20

• increased tension in pectoralis minor
• overuse as accessory respiratory muscle
• postural kyphosis
• direct trauma to muscle
• upper thoracic spinal dysfunction
• costal lesions
• facilitated segment of CT segment

Question 21

Unlar tension glide

Answer 21

• scapular depression
• wrist extension
• finger extension
• elbow flexion
• shoulder abduction
• head tilt to opposite side

Question 22

Median tension glide

Answer 22

• scapular depression
• wrist extension
• finger extension
• elbow extension
• shoulder abduction
• head tilt to opposite side

Question 23

Radial tension glide

Answer 23

• scapular depression
• wrist flexion
• finger flexion
• elbow extension
• shoulder extension
• head tilt to opposite side