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Reflex Sympathetic Dystrophy (RSD) (CRPS) Message Board

Reflex Sympathetic Dystrophy (RSD) (CRPS) Board Index

Re: RSD and TOS
Aug 21, 2006
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here is info on TOS:Pathophysiology: TOS involves compression, injury, or irritation to the neurovascular structures at the root of the neck or upper thoracic region, bounded by the anterior and middle scalenes; between the clavicle and first rib (with possible enlargement/hypertrophy of the subclavius); or beneath the pectoralis minor muscle. Some authors define the thoracic outlet as an opening bordered by the first rib laterally, the vertebral column medially, and the claviculomanubrial complex anteriorly. The syndrome of compression at this site could be primarily neurologic, involving the brachial plexus, most often the lower trunk or medial cord; alternatively, it could involve compression of the subclavian artery, vein, or both. Thrombosis, embolus, or aneurysm of these vessels is a less likely possibility.

One proposed classification system has broken TOS into the following 3 categories:

True neurogenic TOS: The brachial plexus is injured in these cases as documented by electromyography (EMG) and/or nerve conduction studies.

True vascular TOS: The subclavian artery and/or vein is damaged or thrombosed, as documented by arteriogram or venogram.

Nonspecific or disputed TOS: Patients have symptoms, but there are no abnormal tests to document the lesion clearly. This category is by far the most common type of this disorder seen in the clinical setting.
Many authors have discovered accessory cervical ribs associated with TOS; however, they have noted tough fibrous bands coming off the accessory ribs that are believed to be more responsible for the pathology. The bands cause tethering of the brachial plexus, which results in traction and, therefore, symptoms. Other authors report compression or irritation of the neurovascular bundle more distally under the pectoralis minor muscle or from anterior displacement of the humeral head.

Additionally, clavicle fractures can result in plexopathy from expanding hematomas or pseudoaneurysms that compress the plexus, with variable latent periods following the fracture. Delayed onset of symptoms may suggest exuberant callus from the healing fracture site. Nonunion of the fracture site also can result in direct compression by the lateral fragment, which is pulled inferiorly.

More recently, trapezius weakness due to spinal accessory nerve injury (following cervical lymph node biopsy) has been implicated as a cause of TOS. This results in "droopy shoulder" with secondary compression of the neurovascular bundle, particularly aggravated with arm elevation (abduction).

Causes: TOS most likely has multiple causes. The primary cause is believed to be mechanical or postural. Stress, depression, overuse, and habit all can lead to the forward head, droopy shoulder, and collapsed chest posture that allows the thoracic outlet to narrow and compress the neurovascular structures (see Image 1 ). Accessory ribs or fibrous bands also may be present, predisposing the site to narrowing and compression. Large breasts have been implicated as a contributing cause by pulling the chest wall forward (anterior and inferior); this theory has been supported by relief of discomfort following reduction mammoplasty.

Trauma can lead to decompensation or shifting of structures in the shoulder and chest wall, leading to symptom onset. Additionally, trauma with fracture of the clavicle can result directly in compression of the plexus from bone fragments, exuberant callus, hematoma, or pseudoaneurysm.

Primary vascular lesions, such as thrombus or aneurysm, may be present as well as secondary problems such as emboli. Tumors, such as upper lobe lung lesions (Pancoast tumor), are also possible causes.

Many other problems may predispose an individual to TOS, some of which are classic perpetuators of myofascial pain syndrome, including the following:
Sleep disorder
Hormonal imbalance (estrogen, thyroid)
Inflammatory disorder (rheumatoid arthritis)
Nutritional insufficiency (B vitamins, folate, vitamin C)
Masses, tumors, axillary lymph nodes
Mechanical disorders (short leg, hyperlordosis, hypolordosis)
Psychologic (stress, depression)
Nerve entrapment/impingement (other sites)

I will look for more info as for as these docs they are not quacks they are at a teaching hospital one of the best in the country, I'm so lost at this time.

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