21/08/2024
A diagnosis that can present in the body in lots of ways, but all of them deeply uncomfortable or painful. Sometimes it’s not officially diagnosed because MRI doesn't see what the person is experiencing. Diagnosed or not, I believe you and what you're experiencing.
A myofascial massage and nerve gliding can help reduce the nerve compression. Let me help you.
Is neurological thoracic outlet syndrome (N-TOS) really something that you can reliably prove with MRI? TOS is extremely controversial to begin with, and some papers have called it "the most controversial diagnosis in clinical medicine" (Atasoy 1996, Povlsen 2014). One of the main reasons that it remains so controversial and underdiagnosed, is due to the fact - yes, fact - that there are very sparse imaging findings in these patients. Electrodiagnostic findings, as well, unreliable and with poor sensitivity and specificity.
The most common approach for detection, imaging wise, is an upper extremity vasculogram (MRA / CTA) with the arms raised. You are looking mainly for positional obstruction of the subclavian artery, but subclavian vein obstruction is also accepted in some cases. Both findings are known to have false-positive rates, here implied that it can also be found in asymptomatic groups.
If the patient indeed has vascular symptoms, and positive CT angiogram showing subclavian stenosis is relatively conclusive evidence for TOS. But what if the patient has symptoms of N-TOS and only negligible, or absence of vascular symptoms? Is it then also diagnostically reliable?
What if the patient has symptoms of N-TOS and typical clinical triggers (arm loading, static arm positioning, etc) but the electrodiagnostic workup is either normal or comes back "positive" for something else, like carpal tunnel syndrome? Is this reliable? Rousseff, in their excellent 2005 paper showed that 90% of their surgically proven TOS patients had utterly normal electrodiagnostic workups.
Some claim that you can determine N-TOS by the thickness of the scalene muscle appearance on MRI. I have previously shown in some of my papers that you can, perhaps, suggest the presence of TOS by looking - not so much as the thickness - but at the fatty infiltration of the scalenes on ultrasound. This can, however, also be present in asymptomatic patients. The thickness of the muscle bundles is not a very reliable sign in my opinion and experience, but some may differ.
Brachial plexus neurographies have absymal sensitivity for TOS which is why they are reported as normal in almost all instances. Moreover, the typical resolution and slice thickness on these exams are inadequate for the detection of subtle plexus inflammation, even when it is indeed present. It is still helpful to exclude tumors, root avulsions and similar differentials.
So: In TOS, unfortunately, there is not "one" test you can do to conclusively confirm etiology or presence. A series of clinical tests (especially), along with imaging is done both to look for signs of TOS and - improtantly - to exclude mimicking differential diagnoses. TOS is a COMMON disorder that is usually easily diagnosed by an expert, but very difficult to diagnose by someone who is not familiar with its deceptive traits and the inadequacies of its common workup strategies.
I have a large TOS paper coming out that I have been working on for quite some time. Hoping to revise and finally publish it soon.
