Author: E. Paul Giersch

Personal injury attorneys are often in a unique position to view the totality of the injured person’s condition, and to synthesize the diagnostic conclusions of a number of health care providers. This is especially true for clients who are suffering from symptoms of Thoracic Outlet Syndrome.

In cases involving traumatic sprain/strain injuries of the neck, the client may have consulted or been treated by a family practice MD, chiropractor, orthopedist, neurologist, physical medicine specialist, osteopathic physician, or other practitioner of the healing arts. Often the diagnostic impressions generated by the client’s various providers cause the personal injury attorney to wonder if all are referring to the same patient. It seems that the diagnostic paradigms used vary significantly. As a result, the diagnosis of Thoracic Outlet Syndrome may not appear in the medical records, despite a clinical presentation of the signs and symptoms.

Thoracic Outlet Syndrome involves a complex of potential symptoms, caused by compression of the brachial plexus at the thoracic outlet. With chronic contracture of the scalene muscles following injury, the triangular opening formed by the anterior scalene, middle scalene, and first rib is narrowed. The vascular and/or nerve structures of the plexus are compressed, leading to the symptom patterns typical of Thoracic Outlet Syndrome. Most commonly reported symptoms are upper extremity pain or parathesia, headache, neck pain, shoulder pain, chest pain, and upper extremity weakness. Arriving at a Thoracic Outlet Syndrome diagnosis may be difficult because similar symptoms can be found with a herniated disk or impinged nerve root.

Patients with automobile accident whiplash or other neck injury incidents often report symptoms of numbness and/or tingling in the fingers, hands, or arms, especially with elevation, within several weeks or months of injury. Non-leading interview questions aimed at disclosure of common activities (i.e. driving, hair care, washing windows) that prompt such symptoms, should lead to further inquiry.

The vast majority of Thoracic Outlet Syndrome cases are primarily neurogenic, with little or no vascular compromise. Thus, Adson’s Test and other procedures aimed at detecting vascular compression are often not diagnostic. Expensive testing of doubtful utility can be avoided by having your traumatic Thoracic Outlet Syndrome patient undergo a thorough clinical examination by a physician who is familiar with the condition. The clinical exam will usually reveal any vascular component through detection of bruit on aurcultation or diminution of pulse with provocative maneuvering of the arms and hands. Discoloration or temperature difference of the affected extremity may be noted. More precise and sophisticated procedures (i.e. Doppler study) can be reserved for those patients with clinical indications.

A common misconception in the medical and insurance communities is that electrodiagnostic testing can be relied on to confirm or rule out Thoracic Outlet Syndrome. However, negative EMG and nerve conduction studies do not rule out neurogenic Thoracic Outlet Syndrome. Most neurogenic Thoracic Outlet Syndrome patients seek medical care because of sensory nerve-related symptoms (numbness, tingling, pain). Motor ?symptoms are uncommon and appear late. Moreover, positive electrodiagnostic results can be expected only in patients with continuous nerve compression and not the type of intermittent compression commonly encountered. Accompanied by significant expense, little diagnostic value, and high degree of physical discomfort, electrodiagnostic testing should be actively questioned.

Insurance Medical Examination (IME) physicians who challenge the validity of the Thoracic Outlet Syndrome diagnosis in the absence of confirmatory laboratory testing, or because the diagnosis must depend primarily on history and clinical examination, should be referred to histologic studies which have shown abnormalities in the scalene muscle tissue of Thoracic Outlet Syndrome patients. Specifically, Thoracic Outlet Syndrome patients show an abnormal proliferation of Type I (slow-twitch) over Type II (fast-twitch) fibers (the two are normally in approximately equal proportion). Moreover, Thoracic Outlet Syndrome patients show twice or more the amount of connective (scar)tissue in their scalene muscles as control patients. Ongoing research will presumably further establish the objective basis of this scalene-related compression of the brachial plexus, and put an end to assertions that Thoracic Outlet Syndrome is merely a “diagnosis of exclusion.”

Treatment for Thoracic Outlet Syndrome is focused on stretching and relaxing the scalene muscles to allow the vascular and nerve structure to function unimpaired. Conservative treatment such as chiropractic, physical therapy, or massage can be successful in treating Thoracic Outlet Syndrome. When conservative modalities are not successful, surgery may become necessary. Surgery is aimed at releasing the brachial plexus, typically by removing scalene muscle and part of the first rib.
Insurance medical examiners commonly complain about the volume of surgery performed by the handful of specialists who have extensive surgical experience in the area. The same IME doctors are quick to claim that they see the “failures” when those surgical patients require further consultation in search of a remedy. Of course, there is no reason for them to see the “successes,” or to know what success rates are experienced.

It is easy to lose sight of the fact that the few specialists in the community see most of their new Thoracic Outlet Syndrome patients on referral from other doctors. Most of those patients have therefore been pre-screened, with a resulting tentative diagnosis of Thoracic Outlet Syndrome. Furthermore, many of the surgical candidates have already tried the available conservative means of treatment (physical therapy and/or chiropractic) without success.

Establishing the traumatic injury incident as the proximate cause of Thoracic Outlet Syndrome usually requires careful examination of the patient’s treatment records over time to identify symptoms and findings consistent with the diagnosis. Too many personal injury victims have gone through completion of the claim process, suffering from symptoms of undiagnosed and untreated Thoracic Outlet Syndrome. Advising your patient to consult with an experienced personal injury attorney familiar with the literature and condition can be a great asset to the injured person. Capable counsel such as those at Adler Giersch PS can assist by sharing pertinent medical literature with the treating physician and assisting in obtaining insurance company payment for the consultation with an expert experienced in diagnosing and managing the condition.

Sources:

1. Sanders, Richard J.: Thoracic Outlet Syndrome: A Common Sequela of Neck Injuries, Lippencott, 1991.
2. Pollack, Erick W.: Thoracic Outlet Syndrome: Diagnosis and Treatment, Futura Publishing, 1986.