Introduction:
The patient is a 48 year-old woman with a history of
repetitive upper extremity factory work and bilateral carpal
tunnel release in the past. For several years, she noted the
slow onset of severe right shoulder and arm pain, which has
progressively worsened. She had severe sharp pains in the
right neck, shoulder, lateral upper arm, and forearm,
especially with elevation of the arm. There was occasional
numbness and paresthesia. In addition, she occasionally had
grasp weakness, including dropping drinking cups without
warning.
EMG was essentially negative. Cervical spine films revealed
degenerative disc disease throughout the cervical spine
along with osteophytes and narrowing of the right neural
foramina at C5-6 and C6-7. Chest x-ray was negative for
cervical ribs. MRI showed only mild abnormalities and
cervical spine decompression was not felt to be indicated.
Thoracic outlet syndrome (TOS) was felt to be the patient's
primary problem and treatment was suggested. She underwent a
program of physical therapy with which she was quite
compliant but this has afforded little relief.
On examination, she appeared well. The carotid, radial, and
ulnar pulses were strong. There was supraclavicular
tenderness as well as some tenderness in the deltoid region.
The was no edema. The neurologic exam was grossly intact.
Elevation abduction stress test (EAST) was strongly positive
for pain after only 10 sec. She requested surgical thoracic
outlet decompression.
