SCHEUERMANN S DISEASE ASAMODEL DISPLAYING THE MECHANISM … · o riginal c ommunication scheuermann’s disease asamodel displaying the mechanism of venous obstruction in thoracic

� �O R I G I N A L C O M M U N I C A T I O N

SCHEUERMANN’S DISEASE AS A MODELDISPLAYING THE MECHANISM OF

VENOUS OBSTRUCTION IN THORACICOUTLET SYNDROME AND MIGRAINE

PATIENTS: MRI AND MRAJames D. Collins, Ernestina H. Saxton, Theodore Q. Miller, Samuel S. Ahn, Hugh Gelabert,

and Alfred Carnes

Scheuermann’s Disease: An MRI MRA Model Displaying the Mechanism of Venous Obstruc-tion in Thoracic Outlet Syndrome (TOS) and Migraine Patients. Collins JD, Saxton EH, Miller TQ,Ahn SS, Galebert H, Carnes AE Departments of Radiological Sciences Neurology and VascularSurgery, UCLA

Kyphosis of the thoracic spine rotates the scapulae anterior laterally, clavicles and subclaviusmuscles anteriorly, displaces the manubrium posteriorly, which increases the slope of the firstribs. This increases tension on the anterior scalene muscles and the neurovascular bundles whichcauses brachial plexopathy (TOS). Scheuermann’s disease (spinal osteochondrosis; juvenilekyphoscoliosis) is a disorder which consists of vertebral wedging, endplate irregularity andnarrowing of the intervertebral disk space causing kyphosis of the thoracic spine and may alsoinvolve the lumbar space. It occurs at puberty and involves both male and females. Abductionexternal rotation of the upper extremities (arms overhead) posterior inferiorly rotate the claviclesand the subclavius muscles which enhances tension on the venous drainage and neurovascularsupply that diminishes venous return. This triggers complaints of thoracic outlet syndrome (TOS)and migraine headache. Bilateral magnetic resonance imaging (MRI) demonstrates compressingabnormalities of the brachial plexus. Five patients with Scheuermann’s disease were imagedwith the 1.5 Tesla magnet (Signa; General Electric Medical Systems, Milwaukee, WI) 3-Dreconstruction MRI. T1W and T2W pulse sequences were performed in the coronal, transverse,transverse oblique, sagittal, and coronal abduction external rotation planes using 4 mm slicethickness and 512 � 256 matrix size. Water bags were used to enhance the signal to noiseratio. Magnetic resonance angiography (MRA) 2-D Time Of Flight (TOF) was obtained toevaluate perfusion of the brachial plexus. MRI and MRA captured sites of brachial plexuscompression for anatomic display. One patient was selected for this presentation, which dem-onstrates the compression of the brachial plexus and venous obstruction which triggered com-plaints of thoracic outlet syndrome. (J Natl Med Assoc. 2003;95:298–306.)

Key words: MRI } MRA } migraine,nerves imaging } neuropathy }

brachial plexus } Scheuermann’sdisease } thoracic outlet syndrome

INTRODUCTIONMagnetic resonance multi-plane imaging al-

lows bilateral display of the thorax and brachial

plexus in the supine position. This feature gaveus an opportunity to image and study the bra-chial plexus1.

The brachial plexus lies within the fascialplanes of the neck and axilla, which is routinelydisplayed on MRI of the thorax and shouldergirdle2. Abnormalities of the brachial plexusresult from problems with the cervico-thoracic

© 2003. Departments of Radiology (J.D.C., T.Q.M., A.C.), Neurology(E.H.S), and Vascular Surgery (H.G., S.S.A), University of California atLos Angeles, USA. Presented at the National Medical Association104th Annual Scientific Program, Convention and Scientific Assembly,Convention center, Las Vegas, Nevada, August 11, 1999 and at the

Federation of American Societies for Experimental Biology , San Di-ego, California, April 15–18, 2000. Correspondence should be di-rected to James D. Collins Department of Radiological Sciences, Uni-versity of California, Los Angeles, 1083 Le Conte Ave. Los Angeles,CA 90095–0001.

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 95, NO. 4, APRIL 2003 298

segments of the vertebral column, the first rib,clavicle, vascular supply, Manubrium sterni andsoft tissues3. In most individuals, the fascialplane spacing between soft tissues and osseousstructures is adequate to perform routine func-tions without compromising their neurovascu-lar bundles. Studies by Sunderland in 1945 andDyke et al in 1984 suggest that pathology in-volving peripheral nerves alters fascial planes4,5.Acute or chronic changes alter adjacent tissues,thereby compromising the vascular supply ofthe peripheral nerves6. This results in patientspresenting with clinical symptoms of thoracicoutlet syndrome (TOS): tingling, numbness,pain (face, shoulder, upper and lower extrem-ities, back, and abdomen); visual and auditorychanges; syncope and headache (6 FASEB2002).

Knowledge of normal surface and landmarkanatomy is important for interpretation of MRIand MRA studies in patients with brachialplexus injury7. The brachial plexus nerve rootspass with the subclavian artery to form a neu-rovascular bundle between the anterior andmiddle scalene muscles on the first ribs(scalene triangles). The scalene muscles arisefrom the cervical segments of the vertebral col-umn, insert and, in part, support the curved,flat first ribs. The first ribs slope obliquely at-taching to the manubrium to form most of thethoracic inlet. The slope of the first ribschanges with respiration, scoliosis, and kypho-sis of the thoracic spine and affects those struc-tures crossing the first rib, particularly the sub-clavian veins7.

Kyphosis of the thoracic spine occurs inScheuremann’s disease (spinal osteochondro-sis; adolescent kyphoscoliosis), which is an ab-normality in the shape and size of the vertebralbodies of the thoracic and lumbar spine8. Ver-tebral bodies assume wedge shape deformitiesand disk spaces narrowing which contribute tokyphosis of the thoracic spine and abnormalalignment of the shoulder girdle, which alterfascial planes (Figs 1,2).

Thoracic outlet syndrome (brachial plexopa-thy) occurs in patients with Scheuremann’s dis-

ease and other disorders of the cervicothoracicspine9,10. The authors have chosen Scheuer-mann’s disease as a classic presentation in ayoung patient of brachial plexopathy second-ary to kyphosis of the thoracic spine and round-ing of the shoulders. Bilateral magnetic reso-nance imaging (MRI) and angiography (MRA)of the brachial plexus and peripheral nervemake it possible to demonstrate the relation-ship of nerves to their surrounding landmarkanatomy in Scheuremann’s disease patientswith TOS.

All MRI and MRA sequences were cross-ref-erenced in order to arrive at an accurate diag-nosis. It is not possible to present all of theacquired images; the images selected for thispresentation were annotated and best display

Figure 1. PA upright chest radiograph displays the forwardshift of the shoulders with anterior rotated clavicles (C) lowover acute sloping first ribs (FR), and the anterior lateralrotated coracoid processes (CP), reflecting bilateral roundshoulders. The heads of the clavicles (C) are below the fifthposterior ribs (5R). Right and left lung (RL,LL), aorta (A), firstthoracic vertebra (1T).

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the pathologic changes that occur in costocla-vicular compression of the brachial plexus.

METHODS AND MATERIALSPlain chest radiographs (PA and lateral) are

obtained and reviewed prior to the MRI. Theprocedure is discussed and the patient exam-ined. Respiratory gating is applied throughoutthe procedure to minimize motion artifact.The patient is supine in the body coil, armsdown to the side and imaging is monitored atthe MRI station. Magnetic resonance imagesare obtained on the 1.5 Tesla GE Signa MRscanner (GE Medical Systems, Milwaukee, Wis-consin). A body coil is used and intravenouscontrast agents are not administered. A waterbag is placed on the right and the left side ofthe neck to increase signal to noise ratio forhigh resolution imaging. A full field of view (44cm) of the neck and the thorax is used. toimage both supraclavicular fossae. Contiguous(4 mm) coronal, transverse (axial), oblique

transverse, sagittal, and abduction external ro-tation (of the upper extremities) T1-weightedimages, and 2D Time Of Flight (TOF) MRA areobtained. If there is clinical evidence of scar-ring, tumor and/or lymphatic obstruction, FastSpine Echo T2-weighted images are selectivelyobtained. The parameters for acquiring eachsequence have been published1,11,12

CASE HISTORYThis was a 21-year-old right handed female

with the diagnosis of Scheuermann’s disease.She complained of headache with left upperextremity pain, tingling and numbness radiat-ing into the left forearm, elbow and hand; mildtingling and numbness in the right hand;blurred vision and dots in the visual fields; neckpain radiating down into the coccyx, and ring-ing in ears. Elevating her left arm above shoul-der height and combing her hair aggravatedher symptoms. Symptoms began six monthsprior to evaluation by her referring neurolo-gist, and were thought to be the result of pro-longed typing.

Physical examination revealed the bent for-ward neck and the “hunched-up” rounding ofher shoulders, left higher than right, and ky-phosis of the thoracic spine. Swelling and ten-derness were detected over the left supraclavic-ular fossa. Neurological examination revealednegative Spurling’s maneuver; negative Lher-mitte’s sign and Tinel’s sign over the medianand ulnar nerves at the wrist and elbow. Radialpulses were present on abduction external ro-tation of the upper extremities. Roos’ test waspositive on the left and negative on the right.Tinel’s sign in the supraclavicular fossa wasnegative.

The requesting neurologist suspected leftthoracic outlet syndrome (TOS), with denerva-tion of the left ulnar nerve by SSEP testing, notdemonstrated on the right. Upper extremityelectromyogram (EMG) and nerve conductionvelocity study (NCV) indicated no evidence ofleft or right cervical or brachial plexopathy; noleft or right carpal tunnel, Guyon’s, and cubitaltunnel syndromes, and no peripheral neurop-

Figure 2. Lateral upright chest radiograph displays kypho-sis of the thoracic spine and rounding of the shoulders (X)with anterior wedging of thoracic vertebrae (7T, 8T). “Pan-cake shaped” heart (H), humerus (Hu), Manubrium (M).



athy. Because of suspected thoracic outlet syn-drome, the neurologist requested bilateralMRI/MRA of the brachial plexus to determinethe site(s) of brachial plexus compression.

The PA chest radiograph (Fig.1) displayedthe “hunched up” round shoulders; heads ofthe anterior rotated clavicles over the posterior5th intercostal spaces; right first rib higherthan left; normal clear lungs, and small heart.The lateral chest radiograph (Fig. 2) displayedthe thin narrow thorax; forward shift (kypho-sis) of the thoracic spine; mild compression ofthoracic vertebrae (7T,8T), and small heart(H) with round shoulders (X). The arms (HU)were near horizontal, because of expressedpain. It was concluded from the chest radio-graphs that she had bilateral round shouldersaccentuated by kyphosis of the thoracic spine,and anterior wedging of the thoracic vertebrae.

The coronal MRI sequence of the brachialplexus displayed drooping of the small leftshoulder and low left first rib as compared tothe right (Figs 3A,B). The manubrium slopedleft to the smaller hemithorax, tense flat sub-clavian arteries and binding nerve roots on thefirst ribs, left lower than right. The acute de-scent of the clavicles with subclavius musclescompressed (costoclavicular compression) thebicuspid valves13 within the bulbous expandedsubclavian veins and the right internal jugularvein, reflecting decrease venous return (Fig.3B)14, left greater than right. Residual Thymusgland was present within the thymic capsule.

The transverse MRI sequence cross refer-enced the coronal sequence to display the clav-icles and subclavius muscles compressing thebicuspid valves within the subclavian veinsagainst the anterior scalene muscles on the firstribs, left greater than right, and the narrowfascial planes of the supraclavicular fossa (Fig.4). The manubrium sloped left to the smallerhemithorax. The head of the right claviclecompressed the right external jugular vein (notdisplayed) as it joined the compressed brachio-cephalic vein (BRV). The dilated vertebral vein(VV) was compressed against the pleura. Theright sternocleidomastoid muscle (STM) and

large anterior scalene muscle (AS) compressedthe internal jugular vein (J).

The left and right transverse oblique se-quences (not displayed) cross referenced andconfirmed the coronal and transverse se-quences above.

The left sagittal sequence cross referencedthe above sequences to display the thin subcu-taneous tissues, narrow thorax, and forward

Figure 3(A,B). These coronal MRI images display the mid-dle (Fig. 3A) and anterior (Fig. 3B) levels of the thorax. Theleft shoulder droops with the anterior rotated left clavicle(C) and subclavius (SUB) muscle closer to the lower first leftrib (FR) as compared to the right (Figs A,B). Figure 3Bdisplays the right clavicle and subclavius muscle compress-ing the subclavian vein (SV) as the cephalic vein (CV) joinsthe axillosubclavian vein (AXV). Aorta (A), common carotidand pulmonary arteries (CC,P), coracoid process (CP);anterior scalene, deltoid, pectoralis major, sternocleido-mastoid muscles (AS,D,PM,STM); coracoid process (CP),esophagus (E), humerus (H), jugular vein (J), left and rightlungs (LL,RL), middle trunk (MT), Trachea (T), Phrenic andvagus nerves) (PR). vertebral artery (VA), cervical verte-brae2,4,7



shift of the cervicothoracic vertebrae (C7-T3)accentuating the round shoulders (Fig. 5A).The near vertical anterior scalene muscle withthe anterior rotated clavicle and the subclaviusmuscle were in close proximity to the junctionof the internal jugular and subclavian veins onthe pleura secondary to the increased slope ofthe first rib. The subclavian artery and bindingnerve roots were obscured by the gray signalintensity of the middle scalene muscle. Thehigh signal intensity (white) cephalic vein, atthe junction of the deltoid and pectoralis majormuscle reflected decreased venous return.

The right sagittal sequence cross referencedthe coronal and transverse sequences to con-firm the anterior rotated clavicle (C) in close

proximity to the larger right subclavian (SV)and external jugular veins (XJ); compression ofthe brachiocephalic vein at its junction with thevertebral vein (Fig.4); near vertical anteriorscalene muscle (AS) between the subclavianvein (SV) and artery (SA), on the pleura withthe binding nerve roots (Fig. 5B); compressionof the right internal jugular vein, and mildcostoclavicular compression of the right axillo-subclavian vein and artery (not displayed).

The 2D TOF MRA (stacked image, Fig. 6A)displayed the anterior bowed right and leftneurovascular supply (right anterior to thesmaller left) reflecting round shoulders; tensecompression of the second division of the sub-clavian arteries (SA), left greater than right,and the asymmetric compressed subclavianveins (SV), left greater than right. The highsignal intensity left external jugular vein (XJ)joined the internal jugular (J) and subclavian

Figure 4. The transverse MRI cross references Figure 3 todisplay the dilated vertebral vein (VV) invaginating thepleura adjacent to the compressed brachiocephalic vein(BRV) and costoclavicular compression of the narrow fas-cial planes posterior to the clavicles. Gray signal intensitysubclavian (SV), asymmetric clavicles (C) with subclaviusmuscles (SUB) left posterior to right, and the dilated rightvertebral vein reflect decrease venous return. Brachioce-phalic artery and common carotid arteries (BR,CC), esoph-agus (E), jugular vein (J), left and right lungs (LL,RL), spinalcord (SPC), trachea (T), vagus nerve (V); anterior scalene,deltoid, levator scapulae, pectoralis major, sternocleido-mastoid, trapezius muscles (AS, D, LE, PM, STM, TRP).

Figure 5(A,B). These images display the sagittal plane atthe middle level of the cervicothoracic spine (Fig.5A) andto the right of midline within the right scalene triangle(Fig.5B). Figure 5A displays the forward shift of the cervi-cothoracic vertebrae, 7-T3, 36 degrees forward (left) offthe zero degree vertical axis, and the anterior wedgeshaped deformity of the thoracic vertebrae (7T,8T) reflect-ing rounding of the shoulders and kyphosis of the thoracicspine in the supine position. Figure 5B displays the anteriorrotated clavicle in close proximity to the subclavian vein(SV). Backward manubrium (M) accentuates the narrowthorax. Aorta (A), esophagus (E), trachea (T), anteriorscalene, sternocleidomastoid, pectoralis major, right lung(RL), trapezius muscles (AS,STM,PM,TRP), spinal cord(SPC), fifth and seventh cervical vertebrae5,7; thoracic ver-tebrae (1T-3T, 7T, 8T), eighth cervical nerve roots (C8).



vein (SV) medial and superior to the com-pressed bicuspid valve of the subclavian vein

contributing to the proximal dilated left axillo-subclavian vein (AXV). The elongated aorta(A) reflected kyphosis of the thoracic spine,and the dilated right vertebral vein (VV) re-flected decreased venous return secondary tocostoclavicular compression

The 3D coronal reconstructed images (Fig.6B) confirmed the stacked image. Gray signalintensities of the right neck and shoulder ve-nous drainage suggested greater costoclavicu-lar compression on the right than left. Thecompression of the right internal jugular vein(J) cross referenced the transverse and rightsagittal sequences above. However, the highsignal intensity of the left external jugular vein(XJ) suggested increased collateral venous re-turn. The proximally dilated left axillosubcla-vian vein (AXV) suggested greater focal com-pression of the bicuspid valve within thesmaller left subclavian vein (SV) as comparedto the right subclavian vein.

Bilateral coronal abduction external of theupper extremities posterior inferiorly rotatedthe clavicles (C) and subclavius muscles (SUB)with posterior anterior medial rotation of thecoracoid processes (CP) enhancing costoclavic-ular compression as above described (Fig. 7).

Figure 6(A,B). Figure 6A displays the two dimensionalTime of Flight (2D TOF) MRA stacked image (arms at theside). The asymmetric forward rotated neurovascularblood supply, right anterior to left reflects the droopingsmaller left shoulder and costoclavicular compression site(X)-between the diminished signal intensity of the subcla-vian veins (SV) and the proximally dilated axillosubclavianveins (AXV) with bilateral compression of the second divi-sion of the subclavian arteries (SA). Vertebral venousplexus of the spinal cord (VP); vertical attitude of the aorta(A) reflecting kyphosis of the thoracic spine; dilated rightvertebral vein (VV), descending aorta (DA); vertebral vein(VV), cephalic vein (CV), left and right (L,R). Figure 6Bdisplays a 3D coronal reconstructed image of the 2D TOFMRA (arms at the side), which cross references and con-firms the stacked image (Fig.6A). The diminished signalintensities of the right internal jugular (J), external jugular(XJ), brachiocephalic (BRV), and subclavian (SV) veins re-flect costoclavicular compression and edema within theright supraclavicular fossa and right neck as compared toleft supraclavicular fossa. The smaller left subclavian artery(SA) is compressed within the scalene triangle, greaterthan the right subclavian artery. The dilated left axillosub-clavian vein (AXV) is larger than the right axillosubclavianvein. Aorta (A), axillosubclavian artery (AX), cephalic vein(CV), common carotid arteries (CC), superior vena cava(SVC), vertebral arteries (VA), vertebral venous plexus ofthe spinal cord (VP); dilated right vertebral vein (VV), leftand right (L,R), saline water bag (W), and site of costocla-vicular compression (x).

Figure 7. This is a coronal abduction external rotation MRimage of the upper extremities (arms overhead). The clav-icles (C) with the subclavius muscles and the coracoidprocesses (CP) enhance costoclavicular compression of thedraining veins and lymphatics of the within the neck andsupraclavicular fossa. Aorta (A), humerus (H), subclavianartery (SA), axillosubclavian, subclavian, brachiocephalicveins (AXV, SV, BRV), common carotid arteries (CC), firstrib (FR), deltoid, sternocleidomastoid muscles (D, STM),superior vena cava (SVC), trachea (T), left and right lungs(L,R).



The low left clavicle with the subclavius muscleand the coracoid process markedly compressedthe draining veins within the neck, supraclavic-ular fossae, and mildly compressed the neuro-vascular bundle, left greater than right. Highsignal intensity internal mammary (IM) andhepatic veins (H) (Fig. 8) displayed decreasedvenous return which caused increased intratho-racic, intraabdominal, and increased intracra-nial pressures14.

Bilateral abduction external rotation of theupper extremities (arms overhead) triggeredimmediate pain with whole arm and handnumbness, left greater than right. Pain radi-ated from the shoulder, down the left tricepsmuscle to the elbow with bilateral throbbingfrontal headache, and blurred vision. Abdo-men and lower extremity complaints were notexpressed.

She was informed of our findings and ad-vised to discuss her problem with the referringphysician. She sought a second opinion. Thesecond opinion agreed with our findings ofbilateral round shoulders, anterior compres-sion of the mid-thoracic vertebrae (Fig. 2, 7T,8T) accentuated by kyphosis of the thoracicspine; bilateral asymmetric costoclavicular

compression (laxity of the erector muscles) ofthe draining veins within the neck, supraclavic-ular fossae (Ieft greater than right), mild com-pression of the neurovascular bundles. She wasreferred to vascular surgery for further evalua-tion for possible scalenectomy and left first ribresection15. Approximately 6 months later, sheunderwent transaxillary first rib, anterior andmiddle scalenectomy with neurolysis of the in-ferior trunk of the left brachial plexus. The leftfirst rib was transected posteriorly to the trans-verse process and disarticulated from the steno-chrondral junction. The sterochondral and ste-roclavicular ligaments, and the subclaviustendon were divided. The surgeon found athick fibrous band originating on the middlescalene muscle, anterior to the subclavian ar-tery, and inserting on to Sibson’s fascia. Theband was resected and removed and in doingso relieved compression and deviation of theT1 nerve root. She tolerated the procedurewell and was discharged for follow up clinicvisits. Following her scheduled recovery period,she was scheduled for physical therapy-specifi-cally designed for TOS patients16.

DISCUSSIONThe PA and lateral upright chest radio-

graphs in this patient displayed bilateral roundshoulders, drooping right and anterior rotatedleft shoulder, and kyphosis of the thoracicspine accentuated by anterior wedging of the7T and 8T vertebrae (Figs. 1,2). Multiplanarhigh resolution bilateral MRI sequences (su-pine position) cross referenced and confirmedthin narrow fascial planes posterior to the clav-icles and subclavius muscles, and drooping(laxity of the erector/sling muscles) of thesmaller left shoulder (Figs. 3,4); costoclavicularcompression of the subclavian veins in the neu-tral position (Fig. 4), and the forward shift ofthe cervicothoracic spine (Fig. 5A). The 2DTOF MRA and 3D reconstructed coronal im-ages documented compression of the drainingveins of the neck, supraclavicular fossae andmild compression of the subclavian arterieswith binding nerve roots (Figs. 6A,B). The ab-

Figure 8. This is an anterior image of the coronal abduc-tion external rotation of the upper extremities sequence inFigure 7. This image displays high signal intensity (white)internal mammary (IM) and hepatic veins (H) reflectingincreased thoracic and abdominal pressure secondary todecreased venous return on a T-1 sequence. First fascicle ofthe serratus anterior muscle (FSA), liver (L), left ventricle(LV), stomach (S)



duction external rotation of the upper extrem-ity sequence (arms overhead) enhanced costo-clavicular compression, greater left than right(Fig. 7), and captured images displaying thehigh signal intensity (white) of obstructed flowwithin the hepatic and internal mammary veinson the T1 weighted sequence. Triggered com-plaints of headache, blurred vision, and ring-ing in the ears reflected costoclavicular com-pression, left greater than right13.

Structural changes in the alignment of thecervicothoracic spine as with kyphosis in thispatient; aging; injuries; illnesses; sedentary lifestyles, and restricted movements with muscledisuse contribute to atrophy of muscles andsoft tissues16. Laxity of the shoulder musclescontribute to costoclavicular compression ofthe venous drainage within the neck, supracla-vicular fossae, and of the neurovascular bun-dles17.

The circulatory system is a closed system.Compression of the venous drainage from pe-ripheral nerves, impedes venous and lymphaticreturn, and in turn increases arterial pressure.Valves are located within veins and lymphaticsto support, assist and direct blood and lymphflow. A bicuspid valve is located near the termi-nation of the internal jugular vein as it joins thesubclavian vein to form the brachiocephalicand innominate veins. A bicuspid valve (ante-rior and posterior cusps) is usually located lat-eral to opening of the external jugular vein13. Ifexternal pressure is applied to the upper ex-tremity, the walls of the draining veins andlymphatics may compress the valves within. Sur-face veins may be observed to dilate reflectinglymph and venous blood back up within softtissues and nerves. Arterial blood flow is im-peded. This inturn may cause increase in in-trathoracic, intraabdominal, and intravascularpressures14.

The simple inflation of a blood pressurecuff, with preserved radial and brachial pulses,may be visually observed to obstruct the drain-ing veins of the upper extremities in patientswithout TOS. They may complain of increasedpressure in their hands and arms; tingling,

numbness, and throbbing pain; discolorationof the fingers and hand; dizzy and light headedsensations with headaches, and blurred visionwith swooshing and ringing in the ears11,17,18.The longer the obstruction, the greater thecomplaints. Triggered complaints reflect ve-nous obstruction below the blood pressurecuff, tourniquet or when hands are applied tosqueeze the upper arm19. This venous compres-sion interrupts the local blood supply from thenerve fibers causing numbness, weakness, pain,and decreased signal conduction velocity.Transient or permanent compression ischemiaif unrelieved progressively affect the nerve fi-bers in increasing numbers and to an increas-ing degree. Pathology develops with edematousswelling and vascular congestion. If the pres-sure is unrelieved and continues to increase,the nerve(s) suffer a first degree or conductionblock injury. Compression ischemia with de-generation and fibrosis develop. In absence ofrelief, the endoneurial tubes and funniculi at-rophy and with increasing ischemia, fibrosisbecomes marked20.

Round shoulders (laxity) associated with ky-phosis of the thoracic spine cause costoclavic-ular venous compression and brachial plexopa-thy21. This form of thoracic outlet syndrome isusually not amenable to surgical treatment inthe older patients, particularly in severe kypho-sis of the thoracic spine9,10.

“You only see what you know”

We have imaged over 3000 patients present-ing with symptoms of TOS reflecting compro-mising or compression abnormalities of thebrachial plexus. It is instructive that these pa-tients have a common MRI/MRA finding, cos-toclavicular compression of the draining veinswithin the neck and supraclavicular fossae trig-gering complaints as above described17,19,21,22,23.

Other possible etiologies of the patient’scomplaints were ruled out by the MRI/MRA.Our narrative presentation included state-ments and descriptions of images not dis-played. A more extensive report for the pa-



tient’s file was supported by all of thesequences including the above selected images.Unlike x-ray images, a diagnosis is not madefrom a single plain film8,23, although chest ra-diographs are correlated with the MRI andMRA for a more accurate diagnosis20. Since it isnot possible to present all of the images, thoseselected best demonstrated the patholo-gy11,19,21,24,25,26.

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12. www.tosinfo.com Thoracic Outlet Syndrome (TOS) In-formation. Website designed by Ramona Tung, 2002.

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14. Best CH, Taylor NB. The physiologiacal basis of medicalpractice. Ed 6th. Baltimore, The Williams & Wilkins Co.1955;152–174.

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16. Lord JW. Critical reappraisal of diagnostic and thera-peutic modalities for thoracic outlet syndromes. Surgery, Gyne-cology and Obstetrics.1989;168:337–340.

17. Collins JD, Disher A, Miller TQ, Shaver ML. The costo-clavicular syndrome as displayed by MRI and MRA: Reformat and3D graphic display compromising brachioplexopathy Clin Anat,1997;10:131.

18. Saxton EH, Collins JD, Miller TQ, Espinoza A. Migrainecomplicated by brachial plexopathy as displayed by MRI andMRA: Aberrant subclavian artery and cervical ribs. FASEB 1998;12:A1110.

19. Collins JD, Saxton EH, Miller TQ, Ahn SS. Venousobstruction in Sphygmomanometric (BP) measurement causesnumbness and tingling; MRI and MRA.FASEB 2000;14:A310.

20. Sunderland S. Nerves and Nerve Injuries, Baltimore,Williams & Wilkins Co.,1968.

21. Collins JD, Shaver ML, Disher A, Miller TQ. Compro-mising abnormalities of the brachial plexus as displayed by mag-netic resonance imaging. Clin. Anat.1995;8:1–16.

22. Collins JD, Disher A, Miller TQ. The vascular supply ofthe brachial plexus as displayed by magnetic resonance imaging:Magnetic resonance Angiography (MRA). Clin Anat 1995;2:155.

23. Saxton EH, Miller TQ, Collins JD. Neurovascular com-pression on MRI in patients with intractable migraine. Cephalal-gia 1999;19:330–301.

24. Collins JD, Shaver ML, Disher AC, Miller TQ. Bilateralmagnetic resonance imaging of the brachial plexus and periph-eral nerve imaging: Technique and three-dimensional color. InManagement of Peripheral Nerve Problems. Omer, G.E., M.Spinner and A.L.Van Beek (ed.). 2nd ed, W.B. Saunders Co.,1998;82–93.

25. Saxton EH, Miller TQ, Collins JD. Migraine complicatedby brachial plexopathy as displayed by MRI and MRA: Aberrantsubclavian artery and cervical ribs. Neurology Reviews, 2001;1:8–11.

26. Tung RH. (2002). Thoracic Outlet Syndrome (TOS)information. Retrieved October 17, 2002, http://tosinfo.com/

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