Thoracic Outlet Syndrome (TOS) Information

Migraine, carpal tunnel syndrome, reflex dystrophy, dystonia, fibromyalgia, impingement, and thoracic outlet syndrome are clinical diagnoses. They are not pathological ( fascial plane alteration ) diseases. They have a pathological cause. The radiologist must know anatomy to make an accurate diagnosis. You only see what you know!

The terms neurogenic and neurovascular are misconceptions. They are clinical terms. Nerves DO have a blood supply! (arteries, veins, and lymphatics)¹ Image the artery and you image the nerve that binds to the artery for its nutrient blood supply. Research shows, compressing a nerve also compresses the blood supply. Laxity of the sling/erector muscles of the shoulder girdle causes costoclavicular compression². Costoclavicular compression of the bicuspid valves within the draining veins of the neck, supraclavicular fossa with lymphatics, diminishes the blood supply. Any decrease in venous return diverts venous and lymphatic flow expanding soft tissues that increases intrathoracic, intracranial, and intraabdominal pressure that triggers TOS complaints³.

Migraine patients with TOS present with upper extremity pain and paresthesias; migrainous headache with or without visual changes (floaters and/or blurred vision); tinnitus; facial, back, chest and leg pain⁴; muscle spasms and dystonia, syncope, hypertension, and upper extremity lymphedema⁵. Some patients present with chronic, debilitating gastrointestinal complaints beyond the nausea and vomiting of the migraine attack and in addition to the usual TOS symptoms⁶.

Thoracic Outlet Syndrome patients display forward rotated shoulders that increases the slope of the first ribs, backwardly displacing the manubrium, posterior right and/or left that crimps the great vessels (like a water hose)⁷. Crimping diminishes nutrient arterial, venous, and lymphatic circulation to the five senses (hearing, sight, smell, taste, touch) that triggers patient's complaints.

Dr. James D. Collins monitors bilateral MRI, MRA, MRV of the brachial plexus at the imaging console without contrast injections and displays landmark anatomy according to grayscale proton density. The grayscale digital images reflect the concentration of proton density or high signal intensity. Generally, a gray scale will show fat as a white (high signal) image, muscle as shades of gray, and decreasing blood flow also in shades of gray. Because excited protons are best imaged in the static state, the flowing state renders a dark or black signal because the excited protons have moved on and are not available for imaging. Therefore, blood is white (high signal) in the static state and black (low signal) in the flowing state. PA and lateral chest and AP cervical thoracic spine radiographs are acquired prior to the brachial plexus imaging. The functional anatomic series, abduction external rotation (AER) of the upper extremities is the last imaging sequence acquired enhancing sites of costoclavicular compression that triggers patients' complaints. Annotation of the images is the key to undertanding the anatomy.

This is one of many legal landmark cases of Thoracic Outlet Syndrome where the use of bilateral MRI/MRA/MRV brachial plexus imaging displayed one of the anatomic causes of TOS. Leslie S. Caplan and Federal Judiciary US District Court⁸. Her benefits were reinstated.

• Download a video of Dr. James D. Collins of UCLA Radiology annotating and interpreting a sample 3D Brachial Plexus MRI/MRA/MRV of a patient with bilateral Thoracic Outlet Syndrome.

• Visit the 3D Brachial Plexus MRI/MRA/MRV Annotated Image Gallery.

• View a list of physicians and other healthcare providers familiar with treating Thoracic Outlet Syndrome.

• Thoracic Outlet Syndrome Publications, Asbestos Publications, Family Practice Recertification Publications, Journal of The National Medical Association Publications (NEW Radiology Rounds column in 2010!), and Lymphatics Publications from Dr. James D. Collins