Migraine, carpal tunnel syndrome, reflex sympathetic dystrophy (RSD) syndrome, dystonia, fibromyalgia, impingement, piriformis syndrome, and thoracic outlet syndrome are clinical diagnoses because what is common to all is a decrease in blood flow. They are not pathological ( fascial plane alteration ) diseases. The pathological cause is based upon the decrease in blood flow. The radiologist must know landmark 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 is compression of the bicuspid valves within the draining veins of the neck, supraclavicular fossa with lymphatics, that diminishes the blood supply to and from the brachial plexus and the rest of the circulatory system. If costoclavicular compression is not corrected, ischemia with degenerative changes and fibrosis develops, not limited to the brachial plexus, but also involving the brain (i.e. short term memory loss). Any decrease in venous return diverts venous and lymphatic flow back into the vertebral venous plexus / Batson's plexus that expands the spinal canal and soft tissues that increases intrathoracic, intracranial, and intraabdominal pressure that triggers TOS complaints as displayed on MRI/MRA/MRV3,4.

Batson's venous plexus, an extensive paravertebral system of valve-less venous channels within and alongside the spinal canal, provides direct venous communication from the peritoneum and lower body to the cranial cavity and spinal canal. Obstructed venous return increases intracranial, intrathoracic, and intra-abdominal pressure. In migraine and TOS patients bicuspid valve compression (costoclavicular) within the veins of the neck and supraclavicular fossae, and neurovascular bundles causes collateral venous return, expands fascial planes, and triggers complaints of upper extremity numbness and tingling; pain; temperature and color changes; visual blurring and floaters; and headache. Obstruction to venous return causes dilatation of Batson's plexus. Lesser recognized symptoms of TOS venous obstruction are neck pain, pain in the hip, groin, and low back, with radicular pain in the leg and feet, reflecting the proximity of the dilated plexus to the disks and spinal nerve roots. Abduction external rotation enhances TOS symptoms and migraine.10

Patients with the clinical diagnosis of migraine (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.

Tinnitus, by definition, is a latin word meaning "ringing" in the ears. Tinnitus in patients with TOS and/or costoclavicular compression is the result of compression of the inferior bicuspid valve of the internal jugular vein. This results in turbulence of the venous return, like pouring water in a glass. The blood backs up into the sigmoid sinus adjacent to the tympanic membrane of the ear that the patient interprets as a low-pitched sound and/or ringing in the ear - that has been described as a swooshing sound. The sounds may be triggered by just placing a turniquet, blood pressure cuff, and/or hands around the upper arm obstructing venous return that triggers complaints in patients with TOS6.

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.

The most common causes of missed diagnosis of Thoracic Outlet Syndrome (TOS)

  1. Nerves do have a blood supply1
  2. Confounding overlapping symtoms associated with degenerative disc disease
  3. Non recognition of the clinical symptoms of TOS (especially in children and teenagers)8
  4. Lack of routine chest radiographs to rule out osseous and soft tissue landmark abnormalities9
  5. Absence of monitored MRI imaging of landmark anatomy (brachial plexus, head and neck, thorax)
  6. Surgery performed without monitored MRI imaging
  7. Non recognition of the enlargement of the thyroid gland compressing the inferior bicuspid valve within the internal jugular veins
  8. Non recognition of the increased slope of the first ribs backwardly displacing the manubrium crimping (like a water hose) the great vessels
  9. Lack of recorded blood pressure measurements by the physician and the omission of the Adson's maneuver during the physical examination
  10. Obstruction of venous return triggers complaints of vertebral venous plexus/batson's plexus radiculopathy/radicular pain10,11

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 understanding the anatomy.



Cases
Upcoming Presentations with Dr. Collins

James D. Collins, M.D. is a full-time Professor and General Radiologist in the UCLA Department of Radiological Sciences. He specializes in bilateral 3D MRI/MRA imaging of the brachial plexus, and has been performing these studies since 1985. The bilateral 3D MRI/MRA has provided anatomic evidence of thoracic outlet syndrome (compression of the bicuspid valves within the internal jugular and subclavian veins) for neurological evaluation and corrective physical therapy and surgery. The entire procedure is monitored by Dr. Collins at the workstation. After the MRI/MRA/MRV imaging is complete, Dr. Collins spends a great deal of time annotating images and explaining his findings to his patients. He is a favorite of patients, past and present.

Dr. Collins has published extensively in journals such as Clinical Anatomy and Family Practice Recertification. He is a member of many professional societies, including the American Association of Clinical Anatomists (AACA), the British Association of Clinical Anatomists (BACA), the American Association of Anatomists (AAA), the Radiological Society of North America (RSNA), the California Radiological Society (CRS), the Los Angeles Radiological Society (LARS), the Radiology Section of the National Medical Association (NMA), and the Alpha Omega Alpha (AOA) Honor Medical Society. Dr. Collins is currently the radiology editor for the Journal of National Medical Association and Radiology Rounds Section Editor for the Family Practice Recertification.

Brachial plexus and lymphangiograms with Dr. Collins may be scheduled through the UCLA Radiology scheduling department at 310.301.6823.







References

[1] Clinical Anatomy volume 8 issue 1, pages 1-16 Wiley-Liss January 24th, 2005. Compromising abnormalities of the brachial plexus.

[2] FASEB Journal Vol. 21, No. 5 A623.4, p. A600. April 2007.

[3] BEST CH, Taylor NB. The Physiological Basis of Medical Practice, ED 6th Baltimore, p. 152-174, 1955

[4] FASEB Journal Vol. 22, No. 7, A583.4, April 2008.

[5] Journal of National Medical Association 1986 September; 78(9): 875, 878-881 False - Positive Thromboscintigram Resulting From Lymphedema — A Roentgen Pathological Model

[6] FASEB Journal Vol. 20, No. 4, A449-A450, March 6, 2006

[7] FASEB Journal Vol. 23 474.4, 2009

[8] FASEB Journal Vol. 26 526.8, 2012

[9] Clinical Anatomy volume 23:474-493 Wiley-Liss July 14th, 2010. Missed cervical ribs on plain radiographs alter management of thoracic outlet syndrome patients.

[10] Clinical Anatomy volume 20:716-717 Wiley-Liss June 16th, 2007. Batson’s plexus obstruction causes spinal and radicular pain in patients with thoracic outlet syndrome (TOS) and migraine: MRI/MRA/MRV.

[11]FASEB Journal Vol. 27 742.6, 2013. Obstruction of the thoracic duct(s) causes chronic lymphedema of the upper limb in patients presenting with symptoms of thoracic outlet syndrome: MRI/MRA/MRV




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High resolution imaging courtesy of ucla radiology media center.
Acknowledgements to David Nelson and Steven Do @ucla radiology media center.

[Last update: Wednesday, August 13th, 2014]