(1)
Department of Neurosurgery, University of Wisconsin, Madison, WI, USA
14.1 Case Presentation
A 26-year-old male complains of pain in the right side of the neck and scapular area, as well as numbness in the ulnar aspect of the forearm and pain in the ring finger. He has had those symptoms for almost 3 years. They are worse when the arm is elevated beyond 90°. His right forearm and hand fatigue easily especially with typing, writing, and driving. PMH: positive for migraine headaches and endoscopic sinus surgery. Motor examination reveals weakness of his right triceps 4+, APB 4+, ADQ 4+, and IO 5−. The remaining muscle groups are 5/5. There is decreased light touch sensation over the right ulnar aspect of the forearm and hand. He has a Tinel’s sign over the right ulnar n at the elbow and the right supraclavicular area.
14.2 Questions
- 1.
What is the differential diagnosis?
- 2.
What other signs do you look for?
- 3.
How do you work this up?
- 4.
What is the plan for treatment?
Answers
- 1.
Differential diagnosis includes cervical radiculopathy versus thoracic outlet syndrome (TOS ) versus ulnar neuropathy at the elbow. The latter is less likely because the sensory loss involves the medial aspect of the forearm as well, which is supplied by the MABC . The fact that the symptoms worsen with overhead moves favors more TOS. The weakness in the triceps and hand intrinsics localizes the lesion to the middle and lower trunks of the brachial plexus .
- 2.
Special tests for TOS ; they were all positive on the right side of this patient (they could also be positive in asymptomatic subjects):
- (a)
Adson test: ipsilateral (or contralateral) head turn and extension, arm hanging (slight shoulder abduction), and deep breath → radial pulse decreases or obliterates.
- (b)
Halstead maneuver: exaggerated military position (shoulder retraction and extension) → radial pulse decreases or obliterates.
- (c)
Wright test: shoulder hyperabducted (arm over the head), elbow flexed → radial pulse decreases or obliterates.
- (d)
Roos overhead exercise test: arm abducted 90°, externally rotated, elbow 90°, and repeated opening and closing of the hands for 3 min (now 1 min) → reproduces symptoms.
- (e)
Upper limb tension test : arms abducted 90°, elbows extended, wrists extended, and contralateral head tilt → reproduces symptoms (also positive in radiculopathy ) [1].
- (a)
- 3.
The following studies can be ordered:
- (a)
MRI of the cervical spine: this was negative for disc disease.
- (b)
EMG / NCS : Normal
- (c)
CT of the cervical spine: No cervical rib or Pancoast tumor .
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- (a)
