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WHAT IS TOC? CARLOS A. SELMONOSKY, M.D. RICHARD J. SANDERS, M.D. E.W. POLLAK, M.D. HOW IS IT DIAGNOSED? Symptoms- These abnormalities or variations of the anatomy of this area produce symptoms of thoracic outlet syndrome that have been triggered by trauma or repetitive work. The symptoms may spontaneously occur because there are patients who have symptoms of thoracic outlet syndrome without a history of trauma or repetitive work. The compression occurs in three anatomical structures, arteries, veins and nerves; isolated, or more commonly two or three of the structures are compressed. Compression can be of different magnitude in each of these structures. Therefore symptoms can be protean. For example, the subclavian vein can be the only compressed structure and this patient might have a thrombosis of the vein that was called in the past effort thrombosis, or a swelling of the fingers. The subclavian artery can also be compressed with symptoms of temporary, arterial, positional insufficiency of the upper extremity. When they are present for a long time, aneurysm and thrombosis of the subclavian artery may develop with distal embolization. Nerve compression of the brachial plexus is very common and is or not associated with venous or arterial compression. Neurocompression can exist without vascular compression. The intermingling of all this compressions, the degree, and which of the three anatomical structure is the most compressed, might produce protean manifestations of the symptoms in these patients. They are difficult to interpret unless the health provider is aware of the symptoms and the physical examination of thoracic outlet syndrome. If any individual who has a predisposition for thoracic outlet syndrome performs repetitive work with the upper extremity, it is very likely that he will begin to have symptoms in the first few months after he or she starts to work. On the other hand, some people who may have predisposition may take a longer time and it would take years of repetitive work to show the symptoms of thoracic outlet syndrome. They may have had symptoms for a long time, without being aware of them, and at one point in time the symptoms become worse and this is when they are first noticed. The individual is affected because he feels tinglingness and weakness and heaviness of the hands and arms, pains in the chest, pain in the upper back and in the neck. It is difficult now to perform the same type of work that before was easy to do. Also the weakness of the hands, sometimes dropping of objects, make it difficult to perform repetitive work. What symptoms does the patient have? The patient may have few or many symptoms. You can see in the web page the origin of the symptoms, the name of the symptoms, and how they can be classified; they can be together, separate, or isolated and can have a venous, arterial, or neurologic origin. The symptoms also refer to the structure that is compressed and the degree and the association with the others. Some of the manifestations are protean, like anterior chest pains, and if the doctors are unaware of this manifestations, the diagnosis is difficult to make. Physical Exam- Diagnostic Questionnaire The Thoracic Outlet Clinic has developed a detailed questionnaire which allows an assessment of your complaints, and gives an approximate idea about the possibilities of your symptoms being Thoracic Outlet Syndrome. THIS IS NOT A MEDICAL DIAGNOSIS, neither should you personally take action based on the report generated by examining your answers to the questions. This report should be examined by your local medical provider, which will help him/her determine a definite diagnosis and treatment of your problems. A detailed health and complaint questionnaire will be sent to you after a fee of $250.00 has been received by our office. You should answer the questions to the best of your knowledge. Instructions will accompany the questionnaire. Send back your answers in the pre-paid envelope and from ten (10) to fourteen (14) days, you will receive the assessment. With this information, which is not a definite medical diagnosis, you should consult your local physician. The report will empower you with precise information about your problems and therefore your medical provider will be able to maximize the help that he/she can provide for you. There will also be a telephone number which you can call if you have any questions. We hope that this approach may help you to find the source of your problems and allow you to get better help from your medical provider. TOS CLINIC Office: (706) 636-3005 (706) 635-5033 Medical Articles PRESENTED AT THE ANNUAL SCIENTIFIC MEETING OF THE SOUTHERN MEDICAL SOCIETY NASHVILLE, TN OCTOBER 14,1990 BRACHIAL ENTRAPMENT NEUROPATHY IN THE DIAGNOSIS OF CHEST
PAINS. The accurate diagnosis of chest pain remains difficult in spite of newer and more sophisticated tests. Normal coronary angiograms are found in 20-60% of patients with ,chest pains thought to be of coronary origin. Persistent disability in these patients is costly in economic terms and personal suffering. Although the esophagus can be the cause of chest pains, a large number of patients with chest pains have both normal coronary angiograms and esophageal function tests. Brachial entrapment neuropathy associated with thoracic outlet syndrome is likely to be responsible for the chest pains experienced by this group of patients. Its unusual characteristics may be responsible for it remaining undiagnosed in a large number of cases. The complex symptomatology and the clinic diagnosis will be discussed. Neurological tests are not yet available to confirm the diagnosis. Positive neurological tests such as nerve conduction tests, F-wave, evoked potentials, and EMG are only indicative of complications of longstanding entrapment neuropathy. The diagnosis of brachial entrapment neuropathy should be attempted in all patients with chest pains. It can be the only etiological factor in many and frequently coexists with other diseases causing chest pains. SOUTHERN MEDICAL SOCIETY REFLEX SYNPATHETIC DYSTROPHY, Reflex Sympathetic Dystrophy Syndrome leads to severe incapacitation at its later stages. The early manifestations occur in the distal portions of the affected extremity. It is associated with excessive stimulation of the sympathetic system due to a nerve entrapment neuropathy. The hyperactivity of the sympathetic system will be manifested by varying degrees of the vasoconstriction of the digital arteries. The diagnosis is usually attempted by complicated and costly methods such as sweat tests, thermography, or bone scans. Early diagnosis will allow prompt therapy. Hyperactivity of the sympathetic system is the first manifestation of post-traumatic Reflex Sympathetic Dystrophy. A simple method to detect it is digital pneumatic plethysmography. The pulse volume curves obtained by digital pneumatic plethysmography are similar to the curves obtained by the intra-arterial recording of blood pressure. There is a family of curves indicating different degrees of sympathetic activity. The abnormal curves, ranging from blunting of the peak, loss of the dicrotic notch. or complete flattening of the tracing, will allow early diagnosis. The effects of warm water immersion and pharmacological blocks upon the curves, can be easily be demonstrated. Digital pneumatic plethysmography is a cost-effective, easy to use, non-invasive test. It can be rapidly and reliably taught to medical assistants in the physician's office. The use of digital pneumatic plethysmography in the physician's office will allow early diagnosis of Reflex Sympathetic Dystrophy. Cost savings, patient satisfaction because of early diagnosis, rapid establishment of therapy and the ability to monitor the progress of the disease and the effect of therapy will be the benefits of its use. POSTER PRESENTATION AT THE MULTIDISCIPLINARY CARDIOVASCULAR CONFERENCE: DUKE UNIVERSITY MEDICAL CENTER 9/21-23/1995 DIGITAL PNEUMATIC PLETHYSMOGRAPHY: A WINDOW TO THE SYMPATHETIC SYSTEM FUNCTION Twenty to thirty percent of all nerve fibers are anatomically and physiologically sympathetic. In spite of these facts the examination of the sympathetic system is not a part of the physical examination of patients. A few specialized laboratories perform these tests which are complicated and costly. Digital Pneumatic Plethysmography tracings will show pulse volume curves which are similar to the waveforms obtained by recordings of intraarterial blood pressure. Different degrees of sympathetic activity are reflected in a family of curves. The abnormal curves range from loss of the dicrotic notch, blunting of the peak or completely flattening of the tracing. Digital vasoconstriction is a manifestation of sympathetic hyperactivity of the extremities and is not always associated with a sudomotor response. The vasoconstriction is regional in nature and dependent on the nerve or plexus affected. It will be manifested as a change in the arterial digital waveforms. If sympathetic hyperactivity is found when using digital pneumatic plethysmography as a screening test, its causes can be sought. The screening digital pneumatic plethysmography may be as important as screening the blood pressure. Vasoconstriction is a commonly used term in medicine, with digital pneumatic plethysmography it can be objectively documented. The effects of warm or cold water exposure, pharmacological agents, sympathetic block, and sensory, or psychological excitation upon the sympathetic system can be easily documented. The effects of excitation of receptors by different stimuli in the sympathetic system can be objectively documented in a similar way that intraneural activity recording is done but non-invasively. Digital pneumatic plethysmography is a cost effective, easy to use, non invasive test, which requires little training and maintenance. The testing of sympathetic function can be done easily in the doctor's office. It will bring patient satisfaction because of early diagnosis of the sympathetic dysfunction, rapid therapy, and the possibility of monitoring the progress of the disease and the effect of therapy. CARLOS A. SELMONOSKY, M.D., ANNUAL CLINICAL MEETING AMERICAN ACADEMY OF PAIN MANAGEMENT
SEPTEMBER 18-21,1997 AN ALGORITHM FOR THE DIAGNOSIS OF THORACIC OUTLET SYNDROME Thoracic Outlet Syndrome is a group of symptoms arising not only from the upper extremity, but also from the chest, neck, shoulders, and head. The symptoms are produced by a positional, intermittent compression of the brachial plexus, and/or the subclavian artery and vein and the vertebral artery. The diagnosis is made easier by the physician's awareness of the symptoms and by the use of a triad consisting of supraclavicular tenderness, paresthesias and/or pains, and/or paleness of the hands on elevation of the arms and hands, weakness of the abductors and adductors of the fourth and fifth fingers. A diagnostic algorithm based on the symptoms, physical examination, digital pneumatic plethysmography, and the Zung Test for depression will be presented. The methods used for diagnosis and the fourteenth sub sets of patients obtained using this algorithm and a description of each of them will be discussed. The advantages and the usefulness of this algorithm is based on the validity of the methods used. The use of this algorithm will allow the Pain Diagnostician to separate Thoracic Outlet Syndrome from other entities and to assess the correctness of the diagnosis and to justify the usefulness of the diagnostic methods used. CARLOS A. SELMONOSKY, M.D. NORTH GA. ANNUAL CLINICAL MEETING AMERICAN ACADEMY OF PAIN MANAGEMENT
THE DIAGNOSIS OF THORACIC OUTLET SYNDROME BY DIGITAL PNEUMATIC PLETHYSMOGRAPHY. DETECTION OF VASCULAR AND NERVE COMPRESSION Thoracic Outlet Syndrome is a group of symptoms arising not only from the upper extremities, but also from the chest, neck, shoulders, and head. The symptoms are produced by a positional intermittent compression of the brachial plexus and/or the subclavian artery and vein. The diagnosis is made easier by the physicians awareness of the symptoms and by the use of a diagnostic triad. The vascular manifestations of subclavian artery positional temporary compression can be detected by digital pneumatic plethysmography. Changes in the wave forms as obtained by digital pneumatic plethysmography can be objectively documented. The positional compression of the subclavian artery is not uniform, the worst compression can be present in the neutral position. One of the manifestations of nerve compression is sympathetic hyperactivity, 15 to 25% of nerve fibers are of sympathetic origin. This hyperactivity results in digital vasoconstriction detected by digital pneumatic plethysmography. A large number of patients with Thoracic Outlet Syndrome show this digital vasoconstriction. The normal wave forms become blunted or flattened according to the degree of sympathetic hyperactivity. The diagnostic capabilities of digital pneumatic plethysmography in 100 patients with Thoracic Outlet Syndrome will be presented. CARLOS A. SELMONOSKY, M.D. PRESENTED AT THE ANNUAL SCIENTIFIC MEETING OF THE SOUTHERN MEDICAL SOCIETY, NEW ORLEANS, LA OCTOBER 28-31,1993 THE DIAGNOSIS OF CERVICOLUMBAR ROOT COMPRESSION BY AN INEXPENSIVE INFRARED NON-CONTACT THERMOMETER. The compression of a nerve root can be manifested by symptoms and signs in the corresponding dermatome. These symptoms and signs are frequently not reliable, unless there is a severe sensory or motor impairment. In the majority of the patients ill-localized pains or paresthesias are the norm. If the compression of the nerve root is persistent, the skin surface , innervated by the compressed root will be colder than the surrounding areas. Studies of the temperature of the skin in dermatomes C3 to SI were performed in 20 patients. All of these patients had a cervical or lumbar x-ray and MRI or CT scans. A significant correlation was found between the results of the infrared on-contact thermometer and the reports of the imaging tests. Decreases in the temperature of the dermatomes was reflected in a corresponding anatomical pathology in the cervical and lumbar spine x-rays and/or the CT scans or MRI. The correlation was not exactly at the same spinal level, because the thermatomes do not correspond with the dermatomes. Also, there normally is a superimposition of contiguous dermatomes. A simple office procedure was able to detect pathology similar to the one obtained by the CT scans or the MRI. Therefore, the MRI or the CT scans are not indicated as the first line of diagnosis, unless and operation is planned, and more precise localization is needed. An abnormal infrared non-contact then-nometry will give information similar to the results of the MRI or the CT scans. A normal infrared non-contact thermometry is sufficient to eliminate the CT scans or the MRI as diagnostic tests of nerve root compression because no further information will be obtained. The savings to the patient and to the health care system could be enormous if this method is widely used. CARLOS A. SELMONOSKY, M.D., Chest Pains & TOS NORMAL CORONARY
PLETHYSMOGRAPHY From the Greek word "plethysmo", to increase, and "graphos" to write It is the recording of changes in the volume of a limb of digit as blood moves in and out of it with each cardiac cycle. Pneumatic plethysmogaphy uses a pneumatic cuff wrapped around an extremity or digit. By standardizing the injected volume of air and therefore the pressure inside the cuff, momentary volume changes are detected by a transducer and displayed as waveforms also called "pulse volume recordings." These waveforms correspond closely with the waveforms obtained by intra-arterial recording at the same level. BIBLIOGRAPHY: Winsor, T. - Winsor, D. W. Plethysmography; History and
Recent Advances Angiology; 209 - 218; March 1987. NEUROVASCULAR DIAGNOSTIC INSTRUMENT For the diagnosis of: Features: Tests Performed: Overview of the C.E. Vascular Machine The C.E. Vascular Machine is a Pneumoplethysmograph. A pneumoplethysmograph is an instrument which evaluates small amounts of air pressure changes. In the C.E. Vascular Machine, the minute changes in air pressure that occur in a sensing cuff are amplified and filtered to make it possible to measure arterial blood flow. In most cases a cuff is wrapped around a segment, such as a digit (finger) or leg. The cuff is inflated to a pressure that compresses the tissue below it enough to sense the arterial pulses. The pressure most widely used varies from 40mm to 60mm of mercury. The pressure must remain constant in the cuff. Artifacts in the recording are usually caused by leaky cuffs or patient movement. The Arterial waveforin that this machines records is most commonly called a PVR or Pulse Volume Recording. A PVR is a recording of the pulse due to the volume changes caused by pulsatile arterial blood flow. The increase of blood flow is indicated by an rising movement of the recorder stylus (up on the paper or to the left). T'he C.E. Vascular Machine is sensitive enough to be used on digits and on the penis. These locations require high sensitivity due to small amounts of blood flow and the size of the sensing cuff. The manual describes how to use the C. E. Vascular Machine to evaluate arterial pulse waveforins, digital and limb segmental waveforms, segmental systolic pressure, thoracic outlet positional studies, and penile studies. Narrative Digital Pneumatic Plethysmography (DPP) is a cost effective, easy to use, non-invasive test requiring minimum training and maintenance. DPP can be rapidly taught to medical and nonmedical staff. Using pneumatic (air) plethysmography and advanced electronic engineering, DPP consistently provides a qualitative assesment of blood flow. The interpretation of the tracings is not difficult as the following graphics demonstrate. Extensive background literature is available. Representative Tracings Treatment- What is the treatment? The diagnosis is therapy, because these patients may go to numerous doctors but the diagnosis is not entertained. The patient becomes disappointed because of the lack of diagnosis, they also continue to have the pains and frequently they feel that they are judged to be malingering. This puts honest patients in a very difficult position. They may think that they are having mental problems because they know that they have the pains and they are frequently being told that they are exaggerating the symptoms or the doctor can't find anything wrong with them. Many of these patients are depressed, the posture is slouchy. Awareness of this fact and the use of the Zung test is advocated. It is well known that one of the most effective ways to detect depression is to ask the patient. The diagnosis of thoracic outlet syndrome is made easy by using the Selmonosky Triad. The person who is trying to substantiate the claims of the patient or client should know that when a doctor sees a patient with thoracic outlet syndrome, the physician cannot differentiate what has been the triggering factor in the development of the symptoms. If I examine a patient who has thoracic outlet syndrome I am not being told if it was spontaneous, secondary to an accident or trauma, or secondary to repetitive work; I cannot differentiate the causative triggering factor. I can make a diagnosis of thoracic outlet syndrome but the etiological factor can escape at the present time unless there is a severe case of a large cervical rib. Otherwise I cannot possibly decide or make a statement about the etiological diagnosis. The etiological diagnosis cannot be made just with the history and physical examination. Part of the treatment is physical therapy, but with somebody who is aware of thoracic syndrome manifestations and has a special training in the treatment. Some exercises are also very important, correction of the posture, checking that the patient is not depressed. Surgery is the last of the treatment choices and only has to be performed when there is no improvement in the condition. The patient has to be screened by a psychiatrist or a psychotherapist and the patient should know the pros and cons of the procedure and the possibility of failure and damage to the nerves and vessels, and he/she has to be well motivated. There has been evidence in the medical literature that employment in an upper extremity repetitive work has a higher incidence of upper extremity and shoulder problems that include thoracic outlet syndrome. The main point for the insurance companies who are responsible for managed care and Workman's compensation is how we can predict if a worker will develop symptoms of thoracic outlet syndrome before they go to work in a repetitive motion environment. This is an important subject, because if you individualize these patients without discriminating, it could be beneficial, not only for the insurance company, but the industry as well, and especially for the worker because he/she will avoid long-lasting pain problems. TREATMENT OF TOS
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