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TOS differential diagnosis
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TOS differential diagnosis - April 30, 2008 6:42:39 PM
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Kaden
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Okay, so I don't really know why this question popped into my head - I don't currently have a patient example.
...but how would one differentially diagnose a brachial plexus tumor causing thoracic outlet syndrome versus a true TOS?
Now I know neither are all that common but just some food for thought.
I keep imagining a tumor causing TOS symptoms that would be relieved with correctioins we would do with these patients and increased symptoms would be seen with TOS testing
....thus would lead me to believe that it is TOS and continue with treatment.
Not sure what would tip me off to refer back to the MD
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RE: TOS differential diagnosis - May 1, 2008 1:28:13 AM
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bonez
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I think the most likely tumor would be a pancost tumor. These are apical lung tumors that affect the plexus by direct invasion. the patient would look unwell to start weight loss feeling malaise along with motor affects.
I have not seen one but I think that the postural affects that we associate with TOS would likely be absent. Tumors inthis region are seldom bilateral an many patients with TOS will have a bad side but the posture affects will create some symptoms on bote sides.
More rare ones include sentinal node spread from breast and lung to affect the brachial plexus if I remember my neuro these people can also have vocal issues from affects to the recurrent laryngeal nerve.
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RE: TOS differential diagnosis - May 1, 2008 9:22:35 AM
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Alex Brenner PT MPT OCS
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Kaden,
If you suspected a Pancoast Tumor you could order MRI or CT scan of the region. Also, there is usually plexopathy with a Pancoast Tumor that would show up with EMG testing. I am not a big TOS diagnosis believer but both of these tests would be good options to differentiate.
Alex
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RE: TOS differential diagnosis - May 1, 2008 7:57:04 PM
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Kaden
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Thanks guys,
Good points about postural effects and Alex I agree with you about TOS diagnosis.
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RE: TOS differential diagnosis - May 1, 2008 9:14:16 PM
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TexasOrtho
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Kaden. I'm not sure there are any reliable clinical tests for pancost tumor. Most of the literature I've seen indicates imaging (CT and MRI specifically) to be the most specific. I thought this exerpt from emedicine provided a pretty good overview:
"The symptoms are typical of the location of the tumor in the superior sulcus or thoracic inlet adjacent to the eighth cervical nerve roots, the first and second thoracic trunk distribution, the sympathetic chain, and the stellate ganglion. Initially, localized pain occurs in the shoulder and vertebral border of the scapula. Pain may later extend along an ulnar nerve distribution of the arm to the elbow and, ultimately, to the ulnar surface of the forearm and to the small and ring fingers of the hand (C8). If the tumor extends to the sympathetic chain and stellate ganglion, Horner syndrome and anhidrosis develop on the ipsilateral side of the face and upper extremity. Pain is frequently relentless and unremitting, often requiring narcotics for relief. The patient usually supports the elbow of the affected arm in the hand of the opposite upper extremity to ease the tension on the shoulder and upper arm.
The hand muscles may become weak and atrophic, and the triceps reflex may be absent. The first or second rib or vertebrae may be involved by tumor extension and intensify the severity of pain. The spinal canal and spinal cord may be invaded or compressed, with subsequent symptoms of spinal cord tumor or cervical disk disease. Confusion with thoracic outlet syndrome and cervical disk disease is common in the early clinical course. Careful neurologic examination, electromyographic studies, and ulnar nerve studies are performed to verify the precise diagnosis."
Definitely something to watch out for in our patients with TOS or cervical radiculopathy. Whenever I have a smoker with UE symptoms, the Pancoast tumor always pops onto my radar. Given the symptoms overlap and the fact we don't have reliable clinical tests at our disposal, I might suggest using treatment response as a guide. Pancoast tumors are pretty rare, but their 5 year survival is ~30% so it's good to keep in on your radar.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: TOS differential diagnosis - May 3, 2008 11:26:09 AM
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jma
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Great posts on this topic! Informative
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RE: TOS differential diagnosis - May 5, 2008 5:21:14 PM
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Tom Reeves DPT ATC
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From time to time I see a patient with global hypesthesias on one UE. I check TOS tests and they are positive. Since there isn't a nerve that provides coverage for the entire UE, it can't be neurological (unless it is the brain or a giant HNP that is causing compression of the cord and thus simulatiing multi-level nerve root impingement) I work on their posture, do some inferior glide 1st rib mobilization, address ergonomics, and their symptoms go away.
I see maybe 5-6 cases per year and maybe 1/20 don't get better. some have cervical ribs, some can't/won't change their posture.
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RE: TOS differential diagnosis - May 14, 2008 7:48:40 AM
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Alex Brenner PT MPT OCS
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Tom,
I don't doubt your treatment effectiveness; I just have a hard time with the whole TOS diagnosis thing. The problem with all the TOS tests is that they all have poor sensitivity and specificity. School me if I am wrong, but I don't know of any good special tests that support this diagnosis.
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RE: TOS differential diagnosis - May 14, 2008 1:20:59 PM
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TexasOrtho
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There are a few studies that indicate the Roos test can be both sensitive and specific for TOS. I think most of it's specificity is within the first 60 seconds of the exam. I'll try to dig up the reference.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: TOS differential diagnosis - May 14, 2008 1:54:42 PM
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jlharris
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To share a clinical experience I had related to this:
45 y.o. female referred for "neuropathy" in Left UE s/p radiation to left chest for breast cancer 1/2 year earlier. First question I asked was whether she's been screened for metastises which she and her oncologist said yes. Was given self ROM and specific isometrics (UE MMT was <=3/5 for many muscle groups). As we progressed she c/o intermittent changes in functional use of her hand. However, her shoulder and elbow strenght seemed to improve. Pt out of town x 2wks, returns to clinic and c/o loss in hand and UE function from one day to next. With prodding pt admits to finding a lump cephalic aspect of her left chest wall. Refered back to oncologist who found an apical tumor that had invaded her brachial plexus.
I believe the pt had found the lump earlier and kept it to herself. While I felt her sx's and progression did not fit well with expectations, until her return from her trip, I had not aggressively pushed her about self exams and their results. I do not think the outcomes changed b/c of this, but it was a lesson learned.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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RE: TOS differential diagnosis - May 21, 2008 3:27:34 PM
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Alex Brenner PT MPT OCS
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Tom or others,
What is the gold standard for a TOS diagnosis?
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RE: TOS differential diagnosis - May 21, 2008 10:23:36 PM
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TexasOrtho
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Sanders, Richard J. MD a,b; Hammond, Sharon L. MD a,b; Rao, Neal M. BA b Diagnosis of thoracic outlet syndrome. Journal of Vascular Surgery. 46(3):601-604, September 2007.
Thoracic outlet syndrome (TOS) is a nonspecific label. When employing it, one should define the type of TOS as arterial TOS, venous TOS, or neurogenic TOS. Each type has different symptoms and physical findings by which the three types can easily be identified. Neurogenic TOS (NTOS) is by far the most common, comprising well over 90% of all TOS patients. Arterial TOS is the least common accounting for no more than 1%. Many patients are erroneously diagnosed as "vascular" TOS, a nonspecific misnomer, whereas they really have NTOS. The Adson Test of noting a radial pulse deficit in provocative positions has been shown to be of no clinical value and should not be relied upon to make the diagnosis of any of the three types. The test is normal in most patients with NTOS and at the same time can be positive in many control volunteers.
Arterial TOS is caused by emboli arising from subclavian artery stenosis or aneurysms. Symptoms are those of arterial ischemia and x-rays almost always disclose a cervical rib or anomalous first rib. Venous TOS presents with arm swelling, cyanosis, and pain due to subclavian vein obstruction, with or without thrombosis. Neurogenic TOS is due to brachial plexus compression usually from scarred scalene muscles secondary to neck trauma, whiplash injuries being the most common. Symptoms include extremity paresthesia, pain, and weakness as well as neck pain and occipital headache. Physical exam is most important and includes several provocative maneuvers including neck rotation and head tilting, which elicit symptoms in the contralateral extremity; the upper limb tension test, which is comparable to straight leg raising; and abducting the arms to 90[degrees] in external rotation, which usually brings on symptoms within 60 seconds.
My bolds added.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: TOS differential diagnosis - May 22, 2008 6:37:04 AM
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Alex Brenner PT MPT OCS
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I guess what I am getting at is, to have valid sensitivity and specificity values there needs to be a gold standard test. The proposed test should be validated in a second independent group of patients otherwise the results can only be considered tentative and preliminary. I think this is the problem with TOS. I guess from the study Tom listed above, Doppler Ultrasound is considered the gold standard. I am unsure if this test has been validated in a second independent study.
An example of a good gold standard is arthroscopy in diagnosing a meniscal tear. Most of the quality studies that look at meniscal special tests (Thessaly, McMurray, etc) utilize arthroscopy as the gold standard. What better than actually physically viewing the meniscus with a camera?
The problem with TOS is that I don’t think we have a gold standard to even diagnose this condition. Maybe I am wrong.
(edit to change font)
< Message edited by Alex Brenner PT MPT OCS -- May 22, 2008 6:42:22 AM >
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RE: TOS differential diagnosis - May 22, 2008 9:06:46 AM
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TexasOrtho
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We do have gold standards but they are not at the disposal of a physical therapist. The gold standards seem to be vascular and neurological studies. PT's work with what we've got and intepret the results accordingly, giving them the appropriate amount of weight in the clinical exam.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: TOS differential diagnosis - May 22, 2008 11:28:45 AM
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Tom Reeves DPT ATC
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Alex and Rod,
I think we have many places where there is no gold standard that we have access to. I think what Rod said about Doppler being the gold standard for vascular compromise. Its frustrating.
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RE: TOS differential diagnosis - May 31, 2008 11:26:13 AM
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TexasOrtho
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I just started my first class at Texas Tech's doctoral program. The class is called advanced clinical practice for the cervicothoracic joint and thoracic outlet. I just finished a big writeup on pathoanatomy, pathophysiology, and biomechanics of TOS as an assignment. It hasn't been graded, so you'll have to consider the source (me), but it might help a little. There are some really good articles I used to get this stuff from. I'm learning more about the thoracic outlet than I ever thought possible.
Module I: Pathoanatomy, Pathophysiology, Biomechanics of TOS
1a.
1. Is “thoracic outlet” a clinically appropriate term? Which terminology might better encompass the clinical entity “thoracic outlet syndrome”?
The use of the term “thoracic outlet” may not be the most clinically appropriate term for a number of reasons. One of its most significant drawbacks is the lack of consensus between basic and clinical scientists as to what the thoracic outlet actually is. While clinicians have often associated the thoracic outlet as the scalene triangle, anatomists associate the term thoracic outlet with the inferior thoracic aperture. The lack of a clearly defined operational definition may limit the degree of continuity between basic and clinical science, impeding investigations as the most appropriate means of diagnosing and treating clinical “thoracic outlet syndrome”.
The Ranney article proposes a refinement of the term “thoracic outlet syndrome” based on both anatomical and clinical grounds. According to Ranney, these refinements would result in terminology both more precise and useful for the clinician. The proposed anatomic change would be to divide area previously known as the thoracic outlet into cervical and thoracic outlets. The cervical outlet would be a more precise description of the upper roots of the brachial plexus (C5-C7) as they exit the cervical spine into the thorax. The thoracic outlet would describe the exit of structures truly exiting the thorax such as the subclavian artery and lower roots of the brachial plexus.
The clinical diagnosis of “thoracic outlet syndrome” could be modified to be known as “cervicoaxillary syndrome”. As the exact nature of the symptoms becomes known, a more precise clinical diagnosis could be made to reflect the tissues involved. For example, neurogenic signs of the upper brachial plexus without evidence of vascular compromise could be termed cervical outlet syndrome. By extension signs of vascular compromise and/or lower brachial plexus signs might be referred to as true thoracic outlet syndrome.
2. Based on the other readings in this section, and your knowledge of the anatomy in this area, discuss the possible clinical presentation that one could expect at any given site in the “thoracic outlet”.
Given the variety of tissues passing through the cervical and thoracic outlet, we could expect a range of upper-quarter signs including arterial insufficiency, venous insufficiency, neurogenic, and possibly sympathetic signs.
Arterial signs:
· Postural or activity induced claudication of the extremity
· Worsening of symptoms during exposure to cold and improvement with heat
o Patient may report a seasonal variation in symptoms
· Poorly localized upper extremity pain and possibly a “glove” distribution
· Post-traumatic thrombotic or embolic event causing tissue necrosis, ulceration, and even gangrene of the digits (severe cases)
o Most commonly localized in the radial hand
· Positive Adson, Hyperabduction, and 90 degree abduction external rotation test
o These tests have questionable specificity however
Venous signs:
· Affected limb feels weak, swollen, cyanotic after activity
· Deep chest, shoulder, arm pain
· Tingling paresthesias are common
· Positional provocation is possible
Neurogenic signs (most common):
· Most commonly the lower brachial plexus (C8-TI roots)
· Sensory symptoms
o Pain
o Supraclavicular, axillary, cervical (most common)
o Retrosternal or parascapular (less common)
o Poorly localized and often nondermatomal
o Paresthesias
o Generally more localized to C8 through TI dermatomes
o Sensory symptoms often relieved by discontinuing activity or resting arm on a table
· Motor symptoms
o Grip and hand dexterity may be involved
o Intrinsic hand muscle weakness in chronic cases
o Thenar muscle atrophy in chronic cases
· Sympathetic Involvement
o Vasomotor disruption
o Cyanosis during cold or emotional disturbance
o Trophic changes
o Thin skin, nail thickening, loss of hair
1b.
1. Discuss the extrinsic factors that can lead to symptoms of thoracic outlet syndrome.
Extrinsic factors may be thought of as occurring as a result of adaptations from injury or adaptation to repetitive loading. As such, trauma to cervical, thoracic, and upper extremity could be extrinsic causes of thoracic outlet syndrome. Symptoms of thoracic outlet syndrome could be the direct result of the trauma or secondary to injuries to adjacent structures.
Static or repetitive loading could also predispose an individual to thoracic outlet syndrome. For example, the developmental descent of the scapula occurs to a greater degree in women and creates a greater traction on the neurovascular bundle. This process could be worsened in the presence of sloping shoulders or heavy breasts. Lastly, habitual posturing either through vocation or avocation may place greater traction or relative impingement of the neurovascular bundle.
2. How can each one of these extrinsic factors be assessed/uncovered in the clinic, and what is the impact that dysfunction in each joint-complex will have on the thoracic outlet passageways?
Acquiring basic demographic information may assist the clinician’s suspicion of these extrinsic factors. Age, gender, and vocational activities may provide valuable clues regarding the patient’s likelihood for thoracic outlet. The nature of onset could also raise the level of suspicion (traumatic vs. atraumatic).
It is possible that dysfunction of proximal and distal joint complexes could affect the passageways of the thoracic outlet. Injury or dysfunction of the cervical region could affect the size of the scalene triangle. Chronic cervical dysfunction could lead to fibrosis of the scalene and/or scalene triangle and affect the neurovascular bundle. Distally, injuries to the shoulder, elbow, wrist, and hand are likely to affect the neural and vascular trees of the extremity. Altered neurodynamics of these areas could lead to proximal involvement of the brachial plexus.
3. What are the intrinsic factors leading to thoracic outlet syndrome?
Intrinsic factors may be thought of as congenital or acquired. Congenital factors include the presence of a cervical rib. The incidence of cervical rib has been reported in only 1 in 200 individuals however. A more likely congenital anomaly would be the presence of a band of fibrous tissue that run through the thoracic outlet and elevate or kink the neurovascular tissues.
Acquired intrinsic factors may include space-occupying lesions in or around the thoracic outlet. These may include a large callus formation following a clavicular fracture, tumors of the first rib (rare), and a Pancoast tumor. Although rare, the presence of a primary spinal cord or brachial plexus tumor or even an inflammatory lymphadenopathy could encroach upon the neurovascular bundle of the thoracic outlet.
4. Is there a way for the clinician to determine whether any of these intrinsic factors are present in the patient with thoracic outlet syndrome and contributing to the symptoms? How so?
A detailed history could supply the clinician with useful information. However even the most thorough history may not have sufficient specificity to rule in a specific intrinsic cause of thoracic outlet syndrome.
Plain film radiographs would be a relatively simple way to identify a cervical rib or large subclavicular callus. Further diagnostic workup per lymphadenopathy may be indicated (blood panel, imaging, biopsy etc...). This testing would be under the discretion of the appropriate provider.
Clinical testing specific to intrinsic factors listed above is likely to be nonspecific.
1c.
1. What role do muscles play in the development of thoracic outlet syndrome?
The anterior/medial scalene and pectoralis minor have the most direct interaction with the neurovascular bundle. Hypertrophy of the anterior or medial scalene can narrow the outlet and compress the thoracic outlet to greater strain during postural or dynamic activity. Further distally, hypertrophy or tightness of the pectoralis minor could impede the function of the neurovascular bundle as it advances into the proximal upper extremity. Lastly the pectoralis major could exert compressive forces upon the thoracic outlet. The scalene and pectoralis minor can be assessed and treated clinically through manual, passive and active movements.
2. What happens during overhead arm activity that contributes to the pathomechanics of thoracic outlet syndrome?
As the arm is elevated, the neurovascular structures of the proximal and distal thoracic outlet are subjected to varying degrees of stress. Proximally, elevation could produce a narrowing of the subclavicular space in the presence of an elevated rib or previous clavicular fracture.
Distally, the subcoracoid space could provide either a compressive or traction event for the neurovascular bundle during overhead activity. Hyperabduction and external rotation approximates the pectoralis minor to the thorax and expose the nerves and vessels to compression. This event would seem more likely to occur in the presence of a tight pectoralis minor and major.
The more caudal tissues of the brachial plexus, such as the medial cord and ulnar nerve, are placed under greater amounts of tensile forces as the arm is elevated. This could predispose the ulnar nerve to a traction injury causing sensory or motor disturbances. It would seem reasonable that this could be exacerbated by underlying inferior glenohumeral laxity or instability.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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