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The Vicissitudes of the Diagnosis and Surgical Treatment of Neurogenic Thoracic Outlet Syndrome

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Brachial Entrapment Neuropathy in the Diagnosis of Chest Pains

Carlos A. Selmonosky, M.D.

Presented at the Annual Scientific Meeting of the Southern Medical Society

Nashville, TN

October 14, 1990

The accurate diagnosis of chest pain remains difficult in spite of newer and more sophisticated tests. Normal coronary angiograms are found in 20-60% of patients with ,chest pains thought to be of coronary origin. Persistent disability in these patients is costly in economic terms and personal suffering. Although the esophagus can be the cause of chest pains, a large number of patients with chest pains have both normal coronary angiograms and esophageal function tests. Brachial entrapment neuropathy associated with thoracic outlet syndrome is likely to be responsible for the chest pains experienced by this group of patients. Its unusual characteristics may be responsible for it remaining undiagnosed in a large number of cases. The complex symptomatology and the clinic diagnosis will be discussed. Neurological tests are not yet available to confirm the diagnosis. Positive neurological tests such as nerve conduction tests, F-wave, evoked potentials, and EMG are only indicative of complications of longstanding entrapment neuropathy. The diagnosis of brachial entrapment neuropathy should be attempted in all patients with chest pains. It can be the only etiological factor in many and frequently coexists with other diseases causing chest pains.

Reflex Synpathetic Dystrophy, Office Diagnosis by Digital Pneumatic Plethysmography.

Carlos A. Selmonosky, M.D.

Southern Medical Society 89th Annual Scientific Assembly

Kansas City, MO.

November 15-19, 1995

Reflex Sympathetic Dystrophy Syndrome leads to severe incapacitation at its later stages. The early manifestations occur in the distal portions of the affected extremity. It is associated with excessive stimulation of the sympathetic system due to a nerve entrapment neuropathy. The hyperactivity of the sympathetic system will be manifested by varying degrees of the vasoconstriction of the digital arteries. The diagnosis is usually attempted by complicated and costly methods such as sweat tests, thermography, or bone scans.

Early diagnosis will allow prompt therapy. Hyperactivity of the sympathetic system is the first manifestation of post-traumatic Reflex Sympathetic Dystrophy. A simple method to detect it is digital pneumatic plethysmography.

The pulse volume curves obtained by digital pneumatic plethysmography are similar to the curves obtained by the intra-arterial recording of blood pressure. There is a family of curves indicating different degrees of sympathetic activity. The abnormal curves, ranging from blunting of the peak, loss of the dicrotic notch. or complete flattening of the tracing, will allow early diagnosis. The effects of warm water immersion and pharmacological blocks upon the curves, can be easily be demonstrated.

Digital pneumatic plethysmography is a cost-effective, easy to use, non-invasive test. It can be rapidly and reliably taught to medical assistants in the physician's office.

The use of digital pneumatic plethysmography in the physician's office will allow early diagnosis of Reflex Sympathetic Dystrophy. Cost savings, patient satisfaction because of early diagnosis, rapid establishment of therapy and the ability to monitor the progress of the disease and the effect of therapy will be the benefits of its use.  

Digital Pneumatic Plethysmography: A Window to the Sympathetic System Function.

Carlos A. Selmonosky, M.D.

Poster Presentation at the Multidisciplinary Cardiovascular Conference: Duke University Medical Center

November 21-23, 1995

Twenty to thirty percent of all nerve fibers are anatomically and physiologically sympathetic. In spite of these facts the examination of the sympathetic system is not a part of the physical examination of patients. A few specialized laboratories perform these tests which are complicated and costly.

Digital Pneumatic Plethysmography tracings will show pulse volume curves which are similar to the waveforms obtained by recordings of intraarterial blood pressure. Different degrees of sympathetic activity are reflected in a family of curves. The abnormal curves range from loss of the dicrotic notch, blunting of the peak or completely flattening of the tracing.

Digital vasoconstriction is a manifestation of sympathetic hyperactivity of the extremities and is not always associated with a sudomotor response. The vasoconstriction is regional in nature and dependent on the nerve or plexus affected. It will be manifested as a change in the arterial digital waveforms.

If sympathetic hyperactivity is found when using digital pneumatic plethysmography as a screening test, its causes can be sought. The screening digital pneumatic plethysmography may be as important as screening the blood pressure.

Vasoconstriction is a commonly used term in medicine, with digital pneumatic plethysmography it can be objectively documented. The effects of warm or cold water exposure, pharmacological agents, sympathetic block, and sensory, or psychological excitation upon the sympathetic system can be easily documented.

The effects of excitation of receptors by different stimuli in the sympathetic system can be objectively documented in a similar way that intraneural activity recording is done but non-invasively.

Digital pneumatic plethysmography is a cost effective, easy to use, non invasive test, which requires little training and maintenance. The testing of sympathetic function can be done easily in the doctor's office. It will bring patient satisfaction because of early diagnosis of the sympathetic dysfunction, rapid therapy, and the possibility of monitoring the progress of the disease and the effect of therapy.

An Algorithm for the Diagnosis of Thoracic Outlet Syndrome.

Carlos A. Selmonosky, M.D.

Annual Clinical Meeting American Academy of Pain Management

Las Vegas, NV

September 18-21, 1997

Thoracic Outlet Syndrome is a group of symptoms arising not only from the upper extremity, but also from the chest, neck, shoulders, and head. The symptoms are produced by a positional, intermittent compression of the brachial plexus, and/or the subclavian artery and vein and the vertebral artery. The diagnosis is made easier by the physician's awareness of the symptoms and by the use of a triad consisting of supraclavicular tenderness, paresthesias and/or pains, and/or paleness of the hands on elevation of the arms and hands, weakness of the abductors and adductors of the fourth and fifth fingers.

A diagnostic algorithm based on the symptoms, physical examination, digital pneumatic plethysmography, and the Zung Test for depression will be presented. The methods used for diagnosis and the fourteenth sub sets of patients obtained using this algorithm and a description of each of them will be discussed. The advantages and the usefulness of this algorithm is based on the validity of the methods used.

The use of this algorithm will allow the Pain Diagnostician to separate Thoracic Outlet Syndrome from other entities and to assess the correctness of the diagnosis and to justify the usefulness of the diagnostic methods used.

The Diagnosis of Thoracic Outlet Syndrome by Digital Pneumatic Plethysmography. Detection of Vascular and Nerve Compression.

Carlos A. Selmonosky, M

Annual Clinical Meeting American Academy of Pain Management

Las Vegas, NV

September 18-21, 1997

Thoracic Outlet Syndrome is a group of symptoms arising not only from the upper extremities, but also from the chest, neck, shoulders, and head. The symptoms are produced by a positional intermittent compression of the brachial plexus and/or the subclavian artery and vein. The diagnosis is made easier by the physicians awareness of the symptoms and by the use of a diagnostic triad. The vascular manifestations of subclavian artery positional temporary compression can be detected by digital pneumatic plethysmography. Changes in the wave forms as obtained by digital pneumatic plethysmography can be objectively documented. The positional compression of the subclavian artery is not uniform, the worst compression can be present in the neutral position.

One of the manifestations of nerve compression is sympathetic hyperactivity, 15 to 25% of nerve fibers are of sympathetic origin. This hyperactivity results in digital vasoconstriction detected by digital pneumatic plethysmography. A large number of patients with Thoracic Outlet Syndrome show this digital vasoconstriction. The normal wave forms become blunted or flattened according to the degree of sympathetic hyperactivity. The diagnostic capabilities of digital pneumatic plethysmography in 100 patients with Thoracic Outlet Syndrome will be presented.

The Diagnosis of Cervicolumbar Root Compression by an Inexpensive Infrared Non-Contact Thermometer.

Carlos A. Selmonosky, M

Presented at the Annual Scientific Meeting of the Southern Medical Society

New Orleans, LA

October 28-31, 1993

The compression of a nerve root can be manifested by symptoms and signs in the corresponding dermatome. These symptoms and signs are frequently not reliable, unless there is a severe sensory or motor impairment. In the majority of the patients ill-localized pains or paresthesias are the norm. If the compression of the nerve root is persistent, the skin surface , innervated by the compressed root will be colder than the surrounding areas. Studies of the temperature of the skin in dermatomes C3 to SI were performed in 20 patients. All of these patients had a cervical or lumbar x-ray and MRI or CT scans. A significant correlation was found between the results of the infrared on-contact thermometer and the reports of the imaging tests. Decreases in the temperature of the dermatomes was reflected in a corresponding anatomical pathology in the cervical and lumbar spine x-rays and/or the CT scans or MRI. The correlation was not exactly at the same spinal level, because the thermatomes do not correspond with the dermatomes. Also, there normally is a superimposition of contiguous dermatomes. A simple office procedure was able to detect pathology similar to the one obtained by the CT scans or the MRI. Therefore, the MRI or the CT scans are not indicated as the first line of diagnosis, unless and operation is planned, and more precise localization is needed. An abnormal infrared non-contact then-nometry will give information similar to the results of the MRI or the CT scans. A normal infrared non-contact thermometry is sufficient to eliminate the CT scans or the MRI as diagnostic tests of nerve root compression because no further information will be obtained. The savings to the patient and to the health care system could be enormous if this method is widely used.

The Missing Link In The Diagnosis Of Non Coronary Chest Pains
Presented in Rome

Chest pain is an often forgotten symptom of Thoracic Outlet Syndrome (TOS). When trying to establish the etiological diagnosis in patients with Non Coronary Chest Pain (NCCP), the diagnosis of TOS becomes essential. Numerous explanations for the causes of chest pain in NCCP patients were advanced in the past. These explanations covered such diagnosis as esophageal dysfunction, altered coronary flow reserve, endothelial dysfunction, psychogenic, musculoskeletal and central visceral hyperalgesia. However, a cause to effect relationship could not be well established. Although the espohageal etiology may be demonstrated in about 50% of patients with NCCP, there is a sizable number of patients where no diagnosis is established. As these patients quality of life deteriorates, more costly non-diagnostic tests are performed at great expense to health system. The association of TOS with cardiac and esophageal disease is present in about 40% of patients; this association makes the diagnosis difficult for the unaware physician. Diagnosing TOS can be easily accomplished using a diagnostic triad in the physical examination. The triad of signs consists of:

1) Weakness of abduction and adduction of the fifth finger and the pinch strength.

2) Tiredness, paresthesias and/or paleness of the hand on elevation of the upper extremity; marked paleness with cadaveric appearance of the hand is called the White Hand Sign.

3) Tenderness on thumb pressure over the supraclavicular area lateral to the sternocleidomastoid muscle. This diagnostic triad is not present in any other disease or syndrome. A diagnostic algorhythm including TOS has been developed to be used in the approach to "patients with NCCP". The diagnosis of TOS by a diagnostic triad associated or not with the White Hand Sign should be incorporated in the physical examination of all patients with chest pain.

SYMPTOMS FIG 1 Req 2.jpg
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