|
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 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, 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. 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. 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.
James D. Collins is a Professor and General Radiologist in the Department of Radiological Sciences at UCLA. [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 |