Presentation on

Thoracic Outlet Syndrome
by

Dr James Stoxen DC
Presented at the
12th Annual World Congress on Anti-aging Medicine
Mandalay Bay Hotel and Casino, Las Vegas Nevada

December 4, 2004
A presentation of the most effective diagnosis, treatment and prevention of

Thoracic Outlet Syndrome (TOS)

Chapter VII of IX

Differential Diagnosis

Differential Diagnosis

     1.  Klippleflie Syndrome

So in that causative effect in relationship cannot consider these klipplefile ribs, bilateral cervical ribs, anamolists first rib and other findings to be related to thoracic outlet syndrome epidemiology. 

I don’t feel is a cause of thoracic outlet syndrome, I feel that it’s a pre-disposing factor.  I have seen patients who come to me with a lower back pain saying that they have been to their doctor and were told they had scoliosis. And that was the reason they had back pain.  While scoliosis is very minor, and we know that scoliosis does not cause back pain in itself.  The patient actually had some form of biomechanical problem that caused the back pain and the scoliosis was an incidental finding. 

Klippleflie Syndrome predisposes patients to TOS   This is what I call klipplefile syndrome, bilateral cervical ribs, anamolists first rib and other problems that predispose the patient to thoracic outlet syndrome are associated.  In other words, anomalous first rib would be where the ribs are actually not formed according to what we consider normal genetic anatomical structure.  Those will predispose the patient to thoracic outlet syndrome.  Especially if you have a patient who is 19 or 20 who has never had a symptom of thoracic outlet syndrome.  Or if the patient is 25 years, they are at full physical maturity and have had recent thoracic outlet syndrome symptoms.  They have had the anamolists first rib for 25 years but no symptoms, so how is it that all of a sudden that the structures have not changed but the symptoms have been brought on and there is no change in the structure.

     2.  Clavicular Fracture Malunion

Clavicular fracture malunion certainly can be a cause of thoracic outlet syndrome if in fact the malunion is also accompanied by scar tissue formation.  However, I've seen this kind of case in my office before and even with that type of malunion and compression of the thoracic outlet group of structures we found that by adjusting the first rib around that area we have been able to reduce the patient’s symptoms and handle the problem for the patient w/o any surgery. 

 
     3.  Pancost Tumor  

So the differential diagnosis that you want to keep in mind when you’re doing the physical examination are pancost tumors, which are apical lung tumors of course you’re going to do a chest radiograph to determine whether there is any type of lesions in the apical lung area.  Most of the time, these pancost tumors develop on one side, not two; thoracic outlet syndrome is usually a bilateral problem.

     4.  Carpal Tunnel Syndrome 

Carpal tunnel syndrome I feel is very easy do differentiate between thoracic outlet syndrome because if you have a pinching of the nerve, or the vascular supply to the hand, the symptoms will be distal to the compression.  In other words, you shouldn’t have numbness in your forearm with carpal tunnel syndrome. 

     5.  Nerve Impingement (herniated disc) 

        A Cervical Disc Herniation doesn’t always mean Nerve Impingement

In other words, even if I do an MRI scan on a patient and I find that the patient has a posterior herniated disc of 1 to 2 millimeters that is not compressing the nerve according to the radiologist report, my view of the MRI scan, then I don’t feel that that cervical disc is the cause of the peripheral nerve symptoms.  Sure there is a disc, but there is no consequence to the nerve supply.  It’s not pinching anything and should not illicit symptoms.  Sure we have to treat it, but we still have to dig deeper to see where that peripheral vascular type of symptomatology is coming from and you should not overlook the fact that it could be coming from some form of thoracic outlet syndrome.

     6.  Double Crunch - Combined Carpal Tunnel and Nerve Impingement

If you have numbness in your forearm, it cannot be carpal tunnel syndrome unless it’s a double crunch, which is the carpal tunnel syndrome and the thoracic outlet syndrome overlaid over each other where the patient has two problems.  Therefore, the other one could be herniated disc nerve compression.  In this situation, an MRI will rule that out.  You take an MRI and the patient has a cervical disc of perhaps 1, 2, or 3 millimeter, and there is no compression on the fecal sac or nerve bundles, and even though they have a cervical disc, you cannot rule out the fact that they still have a concomitant thoracic outlet syndrome causing the deficit in nerve supply and the concomitant in numbness and weakness.  

     7.  Raynaud’s Phenomenon 

Raynaud’s phenomenon is very similar and differential diagnosis is very difficult at times, because they are very common.  Sometimes I feel Raynaud’s phenomenon is thoracic outlet and at other times I feel that thoracic outlet syndrome is Reynaud’s phenomenon.  There are a lot of patients who are not getting care for thoracic outlet syndrome who have Raynaud’s phenomenon that need to be looked at.  They have similar type of symptoms.  In fact when you cut off or reduce the blood supply to the hand, when you have elevated first rib or scalene swelling causing compression of the subclavian artery, not enough blood supply will get to the distal areas of the fingers and the hands and that is very common in Reynaud’s phenomenon – the coldness.  Subclavian arteries we already discussed. 

     8.  Spinal Cord Neoplasms  

Spinal cord neoplasms, we can differential diagnose that by way of some form of A) diagnostic imaging, and B) with reflex testing, other diagnostic testing can bring out blood tests and an array of evaluations to differentially diagnose spinal cord neoplasms from thoracic outlet syndrome. One other component of thoracic outlet syndrome, which is not commonly mentioned, is that in my opinion the initial symptom is usually the symptoms related to the compression of the subclavian vein.  And I feel the reason is because

A) it is lower in the area of the intrascalene triangle and so its usually the first affected, and

B)  The vein is a drainage, it doesn’t have a muscular layer, it’s more susceptible to compression and we can find the symptoms to see if they have any swelling of the hands and forearms. 

     9.  Brachial Neuritis 

Brachial neuritis usually doesn’t have this vascular symptom. 

     10. Cervical Spondylosis 

Cervical spondylosis is a component of thoracic outlet syndrome. It’s been there for a period of time, and vice versa.

     11. Myofacial Pain Syndrome 

Myofacial pain syndrome, obviously, you’re not going to have the tingling sensations.   You’re not going to have as much of the neurological complaints with myofacial pain syndrome.  However, myofacial pain syndrome in a way is a component of thoracic outlet syndrome because the structures have been subluxated and there is an inflammatory process and swelling and pain going on and that is what myofacial pain syndrome is.  So, there is somewhat of an overlap there. 

     12. Subclavian steel syndrome and angina pectoris 

I have had patients complain of crushing chest pain and shooting pain into the right arm which would mimic a heart attack.  When they go to the hospital for the pain the doctors run the diagnostic tests for heart conditions and find no positive findings for the heart.  When they come to our office and we check them we find that they have a thoracic outlet syndrome.

     13.  Cervical Ribs 

Cervical ribs are anomalous ribs and as I mentioned before, did not cause thoracic outlet syndrome.  Like I said before, just because a patient has scoliosis, it does not mean that we have to do surgery to correct it.  Patients who have scoliosis of 5, 10, 15 degrees live very comfortable and pain free lives.  A patient age 35 walks in the office, which has never had neck, or back pain in their life, they have a recent onset of pain.  You take an x-ray and find out that they have scoliosis.  They had scoliosis when they were 21.  They had scoliosis when they were 15.  They did not have pain at 21 or 15.  The scoliosis has been there for 30 years and is not the cause of the pain in this particular patient. In this situation, if a 35 or 40 year-old patient comes into your office with a recent onset of thoracic outlet syndrome, you take an x-ray of their thoracic and cervical spine and you find that they have cervical ribs.  Just because you find cervical ribs, doesn’t mean that they have to be surgically resected.  If the patient was able to live a comfortable life with those cervical ribs before, my feeling is that all you have to do is reposition the cervical ribs so they do not cause a compressive type of syndrome and the patient will be fine. 

Table of Contents Return...

Chapter I            Dr Stoxen's Introduction                                  Read it here...

Chapter II          Anatomy of Thoracic Outlet Syndrome          Read it here...

Chapter III        Thoracic Outlet Syndrome Controversy         Read it here...

Chapter IV         History or Patient Presentation                      Read it here...

Chapter V           Physical Examination Findings                       Read it here...

Chapter VI         Diagnostic Tests for TOS                                  Read it here...

Chapter VII       Treatment of Thoracic Outlet Syndrome       Read it here...

Chapter IX         Case Histories of Patients with TOS