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1
Ultrasound Imaging of the Brachial Plexus
Thoracic Outlet Syndrome and The Pectoral Bowing Ratio
BENJAMIN M. SUCHER, D.O., FAOCPMR-D, FAAPMR
ETIOLOGY OF TOS
Myofascial v. Ribs/Bands
Between Anterior and Middle Scalenes
Under Pectoralis Minor (against Rib 1,2)Costoclavicular (between Clavicle and 1st Rib)Fibrous Bands-off rudimentary Rib/Transverse
Process- Roots/Plexus “tethered”
Trauma-Episodic
Insidious-CTD, Postural
ETIOLOGY OF TOSMyofascialPectoralis Minor (compressed or ‘tethered’)Cooper’s ligaments - traction
Insidious- Postural
Suspensory LigamentsOften referred to as Cooper's Ligaments, these are the fibrous connections between the inner side of the breast skin and the pectoral muscles. Working in conjunction
with the fatty tissues and the more fibrous lobular tissues, they are largely responsible for maintaining the shape and configuration of the breast. They bear a
major portion of the task of preventing breast ptosis (sagging).
Average weight:2-4lbs each
2
PATHOLOGY / TYPES OF TOS
NEUROGENIC
-True
-Disputed-Nonspecific
-Postural?
VASCULAR-Venous
-Arterial-Mixed
COMBINED
INCIDENCE OF NEUROGENIC TOS
One per Million
Only 250 Surgical Candidates in U.S.
Cherington, et.al., Muscle Nerve, 1988
INCIDENCE OF TOS
23% (2000 PATIENTS) OF SOFT TISSUE
C-SPINE INJURIES
Woods, Modern Medicine, 1978
72% DIAGNOSED INCORRECTLY98% “missed” during initial ED eval
Schukla and Carlton, Southern Med J, 1996
3
THE BRACHIAL PLEXUS
DIFFERENTIAL DIAGNOSIS
RADICULOPATHY
PLEXOPATHY (TOS)
Multiple OtherSites of Compression
Pronator Syndrome
RADIALSpiral grooveTunnel
Guyon’s Canal
Consider:Peripheral NeuropathyCNS pathologyVascular pathologyTendonitisDJD/OARheumatoid DiseaseGanglion, TumorInfection
Anterior Interosseous nerve syndrome
Ligament of Struthers
DIFFERENTIAL DIAGNOSIS OF TOS
1. Carpal Tunnel Syndrome
2. Ulnar Neuropathy-(Cubital Tunnel, Guyon’s Canal)
3. Cervical Radiculopathy
4. Cervical Myelopathy
5. Pancoast Tumor
4
DIAGNOSTIC STRESS TESTS FOR TOS
SCALENE PECTORALIS
Focal Regional Focal Regional
DIAGNOSIS OF TOS – STRESS TESTSAbnormal Results in Healthy Subjects
Maneuver Altered Pulse Pain Paresthesia
Adson’s 11% 0% 11%
CostoClavic 11% 0% 15%
EAST 62% 21% 36%
Supraclav Press 21% 2% 15%
Plewa and Delinger, Acad Emerg Med, 1998
DIAGNOSTIC TESTS FOR TOS
1. X-RAY
2. CT / MRI
3. Doppler / PPG
4. Angiography / Venography
5. EDX- EMG / NCS
6. Autonomic Assessment
7. Ultrasound
5
DIAGNOSTIC TESTS FOR TOS
Anatomic v. Physiologic Vascular v. Neurologic
X-Ray Autonomic
Assessment
MRI Scan
Doppler/Photo-
plethysmography
CT Scan EDX
Angiography/
Venography
Ultrasound Ultrasound
Autonomic Autonomic
Assessment Assessment
MRI Scan MRI Scan
Doppler/Photo-
plethysmography
EDX
Angiography/
Venography
Ultrasound Ultrasound
1. Low amplitude median motor response
…..…………………………………………….Wilbourn5. Abnormal MAC-low amplitude
2. Low amplitude ulnar sensory response
3. Normal median sensory amplitude
4. Neurogenic MUP C8-T1
6. Prolonged F-wave/Axillary F-Loop
7. Abnormal C8 Root Stim (amp / latency)
8. Abnormal Ulnar SEP: N9, N9 -13
ELECTRODIAGNOSIS OF TOS
Wilbourn Tetrad of EDX Abnormalities* with TOS
*In order of prevalence
1. Low amplitude median CMAP < 50% contralateral
2. Low amplitude ulnar SAP < 50% contralateral
3. Normal median SAP
4. Neurogenic MUP C8-T1
5. Relatively low or normal ulnar CMAP
The combination of above findings is “almost distinct for this syndrome”
6
Why Normal EDX in TOS???
“...in moderate compression…normal fascicles adjacent to abnormal fascicles…suggests the basis for the frequent paradox of the patient ..with marked symptomatologybut normal electrodiagnostic findings.
The abnormal findings in the ‘worst’ fascicles account for the patient’s symptoms, whereas the normal large
myelinated fibers in the ‘better’ fascicles account for thenormal electrodiagnostic studies.”
Mackinnon, Hand Clinics, 1992
Ultrasound Imaging of the Brachial Plexus
POSTERIOR
ANTERIOR
L = Lateral Cord PMaj = Pectoralis MajorM = Medial Cord PMM = Pectoralis Minor
P = Posterior Cord AA = Axillary ArteryAV = Axillary Vein
M
P
L
PMaj
PMM
AA
AV
TOS Case #1
48 y/o female with left UE pain, numbness/tingling and weakness, for the
past 2 months. Paresthesias involve the entire hand, especially medial, and medial forearm, worse at night and with driving or keyboard activity,
especially with arms overhead. Treatment with wrist and elbow braces
did not provide relief.
PE: Normal, except for positive Phalen and Tinel testing over the carpal
and cubital tunnels. Posture revealed anterior head/shoulder position,
and thoracic outlet stress was positive with abduction and focal
pectoral stress.
EDX:
Median DML 3.4ms / 13mV [ Ulnar 2.6 / 17mV; no slowing across elbow ]
Median DSL D-1 2.8ms / 32mcv [ Radial 2.5 / 15mcv ]
Median DSL D-2 3.4ms / 38mcv [Ulnar 3.1ms / 39mcv]
Median F-wave 26.0ms
Ulnar F-wave 26.2ms
7
TOS UltrasoundMedial cord plexus irritation
During arm abduction
Pectoralis minor
Axillary arteryPec major
Axillary vein
DIAGNOSTIC ULTRASOUND OF TOS –Abduction Stress - Normal Subject
Neutral – arm adducted at sideNo symptoms
Note linear orientation of pec minor
Abduction stress – 140 degrees No symptoms
Note persistent linear orientation of pec (no indentation)
Note position of plexus to pec minor
(no compression; good clearance)
DIAGNOSTIC ULTRASOUND OF TOS –Abduction Stress Test
Neutral: Arm adducted at side
No symptomsLinear orientation of pec minor
Abduction stress:Progressive, up to 125 degrees
Symptoms exacerbatedNote indentation of pec minor by
Neurovasc bundle from below (dorsal)
EDX:Median DML 2.8ms / 16mV [ Ulnar 2.3 / 15mV; no slowing across elbow ]
Median DSL D-2 3.2ms / 43mcv [ Ulnar D5 = 3.0ms / 32mcv ]
8
TOS Case #252 y/o female with right UE pain, numbness and tingling, for the past month.
Most paresthesias involve the medial forearm and hand, worse with the hand raised overhead (i.e., grooming).
PE: Posture exam revealed anterior shoulder protraction (R>L), and positive
thoracic outlet stress testing (with abduction and focal pectoral pressure).
EDX:
Median DML 3.3ms / 10mV [ Ulnar 3.1 / 12mV; no slowing across elbow ]
Median DSL D-1 2.6ms / 55mcv [ Radial 2.8 / 16mcv ]
Medial Antebrachial Cutaneous amplitude = 8mcv R; 18mcv L
Median F-wave 28.2ms [L side = 27.2]
Ulnar F-wave 27.4ms [L side = 26.4]
DIAGNOSTIC ULTRASOUND OF TOS –Abduction Stress Test (case #2)
Neutral: Arm partially abducted
No symptomsLinear orientation of pec minor
Abduction stress:Progressive, up to 130 degrees
Symptoms exacerbatedNote indentation of pec minor by
Neurovasc bundle from below (dorsal)Medial cord ‘tucked’ against underside of
pec minor; lateral cord is clear
Pectoral Bowing Ratio - Normal
A-B = 28mmC-D = 1mm
C-D/A-B = .036 = 3.6% Pectoral Bowing Ratio
Normal Subject
POSTERIOR
ANTERIOR
Pectoralis minor
ABC
D
9
Pectoral Bowing Ratio - TOS
A-B = 21mmC-D = 5.5mm
C-D/A-B = .262 = 26.2% Pectoral Bowing Ratio
TOS Case
A
BC
Pectoralis minorD
TOS Case #3
41 y/o female with right UE pain, numbness/tingling and weakness, for the
past year. Paresthesias involve the entire hand (all digits), worse at night or with activity (drawing, painting).
PE: Posture exam revealed moderate anterior head protrusion and shoulder
protraction (R>L), and positive thoracic outlet stress testing (with
hyperabduction).
EDX:
Median DML 2.9ms / 19mV [ Ulnar 2.9 / 21mV; no slowing across elbow ]
Median DSL D-1 2.7ms / 39mcv [ Radial 2.7 / 13mcv ]
Median Mixed Nerve latency = 2.0ms [ulnar = 1.9ms]
DIAGNOSTIC ULTRASOUND OF TOS –Abduction Stress Test (case #3)
Neutral: Arm slightly abducted
No symptoms
Abduction stress:Progressive, up to 120 degrees; Symptoms exacerbated
Note indentation of pec minor; Medial and lateral cords ‘tucked’ against underside of pec minor
PBR = 13%
Left sideAsymptomatic
PBR < 1%
10
DIAGNOSTIC ULTRASOUND OF TOS –Abduction Stress Test
39 y/o female with 3mo hx R-UE pain, numbness/tingling, weakness
primarily lateral arm and first 2-3 digits, worse with keyboard use
PE unremarkable: neg Spurling, Tinel, Phalen tests; but posture
revealed anterior/protracted right shoulder, and positive TOS stress
with hyperabduction and focal pectoral pressure.
EDX:Median DML = 2.8ms / 14mV [ulnar 2.6ms/15mV]
Median DSL = 2.6ms / 44mcv [radial 2.4ms/15mcv]
Median F-wave = 25.6ms [ulnar 26.0ms]
DIAGNOSTIC ULTRASOUND OF TOS –Abduction Stress Test (prior case)
Pectoral Bowing Ratio - TOS
Pectoralis minor
c
c = coracoid
28 y/o female with several mo hx R-UE pain, tingling and weakness; all digits, diffuse upper limb symptoms worse with typing, driving and arms elevated
PE unremarkable: neg Spurling, Tinel, Phalen tests; but posture anterior head protrusion and shoulder protraction, and positive TOS stress with hyperabduction.
EDX normal: Median DML = 2.8ms / 14mV [ulnar 2.4ms/18mV] Median; DSL = 2.3ms / 64mcv [radial 2.2ms/25mcv] Median F-wave = 24.2ms [ulnar 23.4ms]
A-A = 15mm B-B = 3.5mmB-B/A-A = .233 = 23.3% Pectoral Bowing Ratio
11
DIAGNOSTIC ULTRASOUND OF TOS –Abduction Stress Test
Neutral: Arm adducted at side
No symptomsLinear orientation of pec minor
Abduction stress:Progressive, up to 125 degrees
Symptoms exacerbatedNote indentation of pec minor by
Neurovasc bundle from below (dorsal)[lateral cord; medial cord on video]
DIAGNOSTIC ULTRASOUND OF TOS –Abduction Stress Test
(prior case)
53 y/o female with 5mo hx R-UE numbness and tingling, primarily in
the first 3-4 digits (and forearm), worse at night and with keyboard use
PE: neg Spurling test, pos Tinel and Phalen tests; posture revealed
anterior/protracted right shoulder, and positive TOS stress w/hyperabduct.
EDX:
Median DML = 4.0ms / 11mV [ulnar 2.8ms/16mV]Median D1 DSL = 2.9ms / 29mcv [radial 2.6ms/13mcv] Dif = .3ms
Median D4 DSL = 3.5ms / 17mcv [ulnar 3.1ms/21mcv Dif = .4ms
Median Mixed latency = 2.2ms [ulnar 1.9ms] Dif = .3msCSI mildly elevated = 1.0ms
DIAGNOSTIC ULTRASOUND OF TOS –Abduction Stress Test
Neutral: Arm adducted at side
No symptomsLinear orientation of pec minor
Abduction stress:Progressive, up to 125 degrees
Symptoms exacerbatedNote indentation of pec minor by Neurovasc bundle from below (dorsal)
[lateral cord ‘flattening’]
44 y/o female with 6 month hx diffuse R-UE pain, tingling and weakness, worse at night.
PE unremarkable: neg Spurling, Tinel, Phalen tests; but posture revealed moderate right shoulder protraction, and positive TOS stress with hyperabduction
EDX: Median DML = 3.3ms / 18mV [ulnar 2.7ms/14mV]Median DSL = 2.7ms / 32mcv [radial 2.7ms/13mcv] Median F-wave = 27.5ms [ulnar 27.2ms]
12
DIAGNOSTIC ULTRASOUND OF TOS –Abduction Stress Test
Neutral: Arm adducted at side
No symptomsLinear orientation of pec minor
Abduction stress:Progressive, up to 135 degrees
Symptoms exacerbatedNote indentation of pec minor by
Neurovasc bundle from below (dorsal)[lateral cord + medial cord]
39 y/o male with 1yr hx diffuse R-UE tingling, worse with activity
PE unremarkable: neg Spurling, Tinel, Phalen tests; but posture revealed moderate anterior head protrusion and right shoulder protraction, and positive TOS stress with hyperabduction
EDX: Median DML = 3.6ms / 14mV [ulnar 3.0ms/17mV]Median DSL = 2.7ms / 41mcv [radial 2.7ms/10mcv] Median F-wave = 27.3ms [ulnar 27.0ms]
THE ELECTRODIAGNOSTIC REPORT
Report the abnormality (Interpretation): Most often: “No abnormalities noted”…..or:
“....prolongation of the F-wave latencies on the left, consistent with proximal slowing (at the plexus level) due to focal demyelination….low amplitude of
the left medial antebrachial cutaneous nerve response, consistent with partial axon loss….”
Summarize with ‘Impressions’ or ‘Conclusions’:1. No electrical evidence of radiculopathy, plexopathy, nerve injury…
2. Left thoracic outlet syndrome (brachial plexopathy) - postural type; electrically negative (or….‘very mild, electrically’)
Diagnostic ultrasound imaging (high resolution, 4-15MHz linear transducer) of the left shoulder(infraclavicular region) reveals normal appearance of the neurovascular bundle and pectoralis
minor muscle (transverse imaging). However, during progressive arm abduction, the medial and lateral cords of the brachial plexus (and axillary artery) contact and ‘indent’ the posterior edge of the pectoralis minor, as upper limb symptoms develop and increase. The pectoral bowing ratio
is abnormally elevated at 120 degrees of abduction to 16.2% (normal <10%).
MANIPULATIVE TREATMENT of TOS
PECTORALISMINOR
13
MANIPULATIVE TREATMENT of TOS
SCALENUSANTERIOR &MEDIUS
PECTORALISMINOR
Ultrasound-Guided Manipulation of TOS
manip of pect minor
Post-manipulation abduction stressNo symptoms; PBR = 0
Pre-manipulation abduction stressSymptoms; PBR = 13.6%
pmaj
pmin
32 y/o female, 18mo hx of left UE pain, numbness, weakness. Numbness into all digits,especially #s 3-5 and medial forearm, worse with arm elevated. EDX completely normal. Posture - protracted shoulder. Positive hyperabduction stress test.
Ultrasound-Guided Manipulation of TOS
Local Twitch Response
14
Ultrasound-Guided Manipulation of TOS
Post-manipulation abduction stressMinimimal symptoms; PBR = 5.9%
Pre-manipulation abduction stressSymptoms; PBR = 16.3%
48 y/o female, several year hx of Right upper limb pain, numbness, and weakness. Numbness into the lateral 3 digits, worse with arm elevated. EDX completely normal. Posture - protracted shoulder. Positive hyperabduction stress test and focal pectoral pressure.
pmaj
pmin
Notice change in lateral cord shape(from oval to ellipsoid)
Ultrasound-Guided Manipulation of TOS
manip of pect minor
Post-manipulation abduction stressNo symptoms; PBR = 4%
Pre-manipulation abduction stressSymptoms; PBR = 11.4%
42 y/o female, 3mo hx of left UE pain, numbness, tingling, weakness. Numbness into all digits,and the forearm. EDX completely normal.
Posture - protracted left shoulder. Positive hyperabduction and focal pectoral stress test.
Ultrasound of the Brachial Plexus -Supraclavicular
C6 roots
Bony tubercles
C7
15
REFERENCES
1. Sucher BM: Thoracic outlet syndrome – A myofascial variant: Part 1. Pathology and diagnosis. JAOA
1990;90:686-704.2. 2. Sucher BM: Thoracic outlet syndrome. In: Plexopathy (section). Physical Medicine and Rehabilitation
(textbook). eMedicine (www.eMedicine.com) April, 2001 (Updated and republished: Feb 25, 2015).3. Mackinnon SE, Patterson GA, and Novak CB: Thoracic outlet syndrome: A current overview. Seminars
in Thoracic and Cardiovascular Surgery 1996;8:176-182.4. Mackinnon SE and Novak CB: Evaluation of the patient with thoracic outlet syndrome. Seminars in
Thoracic and Cardiovascular Surgery 1996; 8:190-200.5. Ferrante MA: Brachial plexopathies: Classifications, causes, and consequences. Muscle & Nerve
2004;30:547-568.6. Wilbourn AJ: Case Report #7: True neurogenic thoracic outlet syndrome. American Association of
Electromyography and Electrodiagnosis. 1982.7. Cuetter, AC and Bartoszek DM: The thoracic outlet syndrome: Controversies, overdiagnosis,
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References (cont)
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