Our Summary

This study discusses the challenges in diagnosing a condition called neurological thoracic outlet syndrome (NTOS), which affects the nerves that pass through the space between your collarbone and your first rib. A subtype called disputed TOS (DTOS) is also mentioned, both of which have a variety of symptoms and causes.

To diagnose this condition, doctors often use a type of MRI called magnetic resonance neurography (MRN) to take detailed images of the nerves near your collarbone. However, this method needs to be adapted to better visualize these nerves and how they relate to nearby bone structures. By moving the patient’s arm during the scan, doctors can see how these movements might compress or narrow the space around these nerves.

In patients diagnosed with NTOS, the MRN can show specific nerves being pinched or irritated, which causes an abnormal signal in the imaging. Certain bone structures or conditions, like an extra rib, fused ribs, or excess bone tissue after a collarbone fracture, can contribute to this condition.

On the other hand, patients with DTOS often show swelling and irritation of the middle part of the nerve bundle, often due to the narrowing of the space between the collarbone and the first rib.

After a detailed diagnosis that often includes a nerve conduction study, doctors can determine the best treatment approach. Non-surgical treatment is an option for all cases of DTOS. However, if patients with either NTOS or DTOS do not respond to non-surgical treatments, they might be referred for a surgical consultation. If surgery is chosen as a treatment option, MRN can be used to help plan the procedure.

FAQs

  1. What is thoracic outlet syndrome (TOS) and its subtypes?
  2. How is magnetic resonance neurography (MRN) used in diagnosing and planning treatment for thoracic outlet syndrome?
  3. When is surgery considered as a treatment option for patients with thoracic outlet syndrome?

Doctor’s Tip

A helpful tip a doctor might tell a patient about thoracic outlet syndrome surgery is to follow post-operative instructions carefully, including proper wound care, physical therapy, and avoiding activities that may aggravate the condition. It is important to communicate any concerns or changes in symptoms to your healthcare provider for proper monitoring and management.

Suitable For

Patients who are typically recommended for thoracic outlet syndrome surgery are those who have failed conservative treatment and have been diagnosed with neurogenic thoracic outlet syndrome (NTOS) or disputed thoracic outlet syndrome (DTOS). These patients may exhibit focal impingement of nerve roots or the lower trunk on MRN imaging, as well as abnormal T2-weighted signal hyperintensity. Patients with predisposing anatomical entities such as cervical ribs or rib synostoses may also be candidates for surgery. Dynamic assessment with arm positioning is used to evaluate outlet narrowing and compression of the plexus, and surgical intervention may be considered if significant impingement is present. Patients with DTOS may also demonstrate signal hyperintensity and enlargement of the mid plexus, with narrowing of the costoclavicular interval. In these cases, surgery may be recommended to relieve compression and improve symptoms.

Timeline

  • Patient experiences symptoms such as pain, numbness, tingling, and weakness in the arm and hand
  • Patient undergoes diagnostic workup including physical examination, imaging studies, and possibly electrodiagnostic testing
  • MRN of the brachial plexus is performed to evaluate nerve compression and abnormalities
  • NTOS patients may show focal impingement of nerve roots and abnormal signal hyperintensity on MRN
  • DTOS patients may show mid plexus enlargement and narrowing of the costoclavicular interval on MRN
  • Patients who fail conservative treatment are referred for surgical opinion
  • Surgery may be recommended for NTOS or DTOS patients, with MRN used for preoperative planning
  • After surgery, patients may experience relief of symptoms and improved function in the affected arm and hand.

What to Ask Your Doctor

  1. What specific subtype of thoracic outlet syndrome do I have (neurogenic TOS or disputed TOS) and how will this impact my treatment plan?
  2. How will magnetic resonance neurography (MRN) help in diagnosing and planning for my thoracic outlet syndrome surgery?
  3. What specific imaging modifications will be used during the MRN to maximize resolution and assess nerve compression?
  4. What specific anatomical factors or abnormalities will the MRN be looking for in relation to my TOS?
  5. How will the MRN help in determining if surgery is necessary for my TOS?
  6. What are the potential risks and benefits of thoracic outlet syndrome surgery in my case?
  7. What is the expected recovery time and rehabilitation process following thoracic outlet syndrome surgery?
  8. Are there any alternative treatment options to surgery that I should consider?
  9. How will my progress be monitored post-surgery to ensure the best possible outcome?
  10. Are there any specific lifestyle changes or precautions I should take after thoracic outlet syndrome surgery to prevent recurrence or complications?

Reference

Authors: Davidson EJ, Tan ET, Sneag DB. Journal: Muscle Nerve. 2024 Dec;70(6):1128-1139. doi: 10.1002/mus.28246. Epub 2024 Sep 10. PMID: 39253948