JHS 49.6 - June 2024 - 693
van der Heijden et al.
693
regrowth of the first rib or impingement by movement
of the remaining rib parts.
There is a group in between recurrent and persistent
who have relief of some of the symptoms but
also have some persistent symptoms. These patients
should be scrutinized to determine if the TOS symptoms
have been successfully treated and the remaining
symptoms are arising from a different origin. This
would be consistent with confirming the diagnosis of
TOS but highlight additional co-existing diagnoses.
An example would be the patient with TOS and
CuTS, or TOS and radiculopathy. This latter group
called partly persistent are the most challenging.
Causes of persistent pain after TOS surgery
Persistent pain after TOS surgery may be due to misdiagnosis,
inadequate or incomplete surgery, continuing
occlusion of TOS by a different structure,
exposure of further peripheral neuropathies or maladaptive
motor patterns.
Removing one cause of nerve compression may
reveal a 'double crush' at a further area along the
course of the nerve. Treatments are targeted to
address these causes, which may include reoperation.
Maladaptive behaviour of trapezius and
levator scapula
Commonly, the majority of the neurological symptoms
have improved but there is persistent shoulder
pain or pain and tenderness within the middle cervical
fibres of the trapezius and levator scapulae near
its insertion to the scapula. This may be due to maladaptive
muscle behaviour with continued muscle
overactivity in the trapezius and levator scapula.
These muscles are overactive in TOS to protect the
plexus by elevating the shoulder, reducing the tension
on the brachial plexus. This learned overactivity
persists even after the plexus has been decompressed.
Physiotherapy and training exercises will
help relieve this maladaptive motor patterning.
These patients may benefit from a corticosteroid
injection into the trapezius or levator scapulae just
above the medial superior angle of the scapula.
Botox can also be used to provide an element of
denervation during which the maladaptive behaviour
patterns can be altered and the symptoms improved.
Diagnosis
Clinical history and examination. When patients present
with recurrent symptoms, efforts must be made
to reinvestigate the original diagnosis to confirm that
the current symptoms are indeed consistent with
TOS. This means performing a full history and
orthopaedic, neurological and vascular examinations.
This includes an examination of the neck and
shoulder, as well as the peripheral nerves.
Examination findings should particularly try to localize
the level or site of the lesion by correlating symptoms
with examination findings and anatomical and
physiological knowledge. Double or triple crush or
multiple neuropathies are common, particularly as
previous nerve injury or lesions may sensitize the
nerve to subsequent areas of compressional or frictional
irritation. Some of these patients may have
other neurological conditions sensitizing them to
develop symptoms and signs. The scratch collapse
reflex test is not a reliable test in this situation.
Investigation. Cervical spine radiograph, cervical and
brachial plexus MRI and neurophysiology should be
performed. It is uncommon for the MRI scan to show
any cause of recurrent TOS but at least it will exclude
cervical pathology, such as radiculopathy, disc prolapse
or cord pathology such as demyelination
plaques.
Similarly, computed tomography or cervical radiographs
may not show any obvious cause but may
show the extent of a regenerated or persistent cervical
or first rib.
Neurophysiology may show changes from the
study performed before the original procedure but
rarely confirms the diagnosis. Its main utility is in
refuting the presence of more distal peripheral neuropathy,
particularly compressive neuropathies such
as CTS or CuTS but equally the presence of other
polyneuropathies, such as diabetic neurofibromatosis,
or rarities like polyneuropathies, such as hereditary
neuropathy with a liability to pressure palsy.
Treatment. Non-surgical: Physiotherapy and other
physical therapies should be attempted to improve
posture, strength and biomechanics of activity. If
investigations highlight other possible causes, such
as radiculopathy, then this should be treated first by
physical therapy, nerve root injection and obtaining a
spinal opinion. Other peripheral compressive neuropathies
should be treated.
Surgical: TOS reoperation is considered if the
diagnosis is confirmed, the symptoms deteriorate
or are unbearable, or if evidence of deterioration is
measurable, such as constant numbness or paraesthesia,
weakness, wasting, fasciculations, tremor,
clumsiness, ischaemia of the digits, thrombosis of
vein or artery, or loss of function. Check and check
again that the diagnosis is not something else, not
peripheral neuropathies, not cerebral, not ischaemic
heart disease, not arthritis and so on.
JHS 49.6 - June 2024
Table of Contents for the Digital Edition of JHS 49.6 - June 2024
Contents
JHS 49.6 - June 2024 - Cover1
JHS 49.6 - June 2024 - Cover2
JHS 49.6 - June 2024 - 660
JHS 49.6 - June 2024 - 661
JHS 49.6 - June 2024 - Contents
JHS 49.6 - June 2024 - 663
JHS 49.6 - June 2024 - 664
JHS 49.6 - June 2024 - 665
JHS 49.6 - June 2024 - 666
JHS 49.6 - June 2024 - 667
JHS 49.6 - June 2024 - 668
JHS 49.6 - June 2024 - 669
JHS 49.6 - June 2024 - 670
JHS 49.6 - June 2024 - 671
JHS 49.6 - June 2024 - 672
JHS 49.6 - June 2024 - 673
JHS 49.6 - June 2024 - 674
JHS 49.6 - June 2024 - 675
JHS 49.6 - June 2024 - 676
JHS 49.6 - June 2024 - 677
JHS 49.6 - June 2024 - 678
JHS 49.6 - June 2024 - 679
JHS 49.6 - June 2024 - 680
JHS 49.6 - June 2024 - 681
JHS 49.6 - June 2024 - 682
JHS 49.6 - June 2024 - 683
JHS 49.6 - June 2024 - 684
JHS 49.6 - June 2024 - 685
JHS 49.6 - June 2024 - 686
JHS 49.6 - June 2024 - 687
JHS 49.6 - June 2024 - 688
JHS 49.6 - June 2024 - 689
JHS 49.6 - June 2024 - 690
JHS 49.6 - June 2024 - 691
JHS 49.6 - June 2024 - 692
JHS 49.6 - June 2024 - 693
JHS 49.6 - June 2024 - 694
JHS 49.6 - June 2024 - 695
JHS 49.6 - June 2024 - 696
JHS 49.6 - June 2024 - 697
JHS 49.6 - June 2024 - 698
JHS 49.6 - June 2024 - 699
JHS 49.6 - June 2024 - 700
JHS 49.6 - June 2024 - 701
JHS 49.6 - June 2024 - 702
JHS 49.6 - June 2024 - 703
JHS 49.6 - June 2024 - 704
JHS 49.6 - June 2024 - 705
JHS 49.6 - June 2024 - 706
JHS 49.6 - June 2024 - 707
JHS 49.6 - June 2024 - 708
JHS 49.6 - June 2024 - 709
JHS 49.6 - June 2024 - 710
JHS 49.6 - June 2024 - 711
JHS 49.6 - June 2024 - 712
JHS 49.6 - June 2024 - 713
JHS 49.6 - June 2024 - 714
JHS 49.6 - June 2024 - 715
JHS 49.6 - June 2024 - 716
JHS 49.6 - June 2024 - 717
JHS 49.6 - June 2024 - 718
JHS 49.6 - June 2024 - 719
JHS 49.6 - June 2024 - 720
JHS 49.6 - June 2024 - 721
JHS 49.6 - June 2024 - 722
JHS 49.6 - June 2024 - 723
JHS 49.6 - June 2024 - 724
JHS 49.6 - June 2024 - 725
JHS 49.6 - June 2024 - 726
JHS 49.6 - June 2024 - 727
JHS 49.6 - June 2024 - 728
JHS 49.6 - June 2024 - 729
JHS 49.6 - June 2024 - 730
JHS 49.6 - June 2024 - 731
JHS 49.6 - June 2024 - 732
JHS 49.6 - June 2024 - 733
JHS 49.6 - June 2024 - 734
JHS 49.6 - June 2024 - 735
JHS 49.6 - June 2024 - 736
JHS 49.6 - June 2024 - 737
JHS 49.6 - June 2024 - 738
JHS 49.6 - June 2024 - 739
JHS 49.6 - June 2024 - 740
JHS 49.6 - June 2024 - 741
JHS 49.6 - June 2024 - 742
JHS 49.6 - June 2024 - 743
JHS 49.6 - June 2024 - 744
JHS 49.6 - June 2024 - 745
JHS 49.6 - June 2024 - 746
JHS 49.6 - June 2024 - 747
JHS 49.6 - June 2024 - 748
JHS 49.6 - June 2024 - 749
JHS 49.6 - June 2024 - 750
JHS 49.6 - June 2024 - 751
JHS 49.6 - June 2024 - 752
JHS 49.6 - June 2024 - 753
JHS 49.6 - June 2024 - 754
JHS 49.6 - June 2024 - 755
JHS 49.6 - June 2024 - 756
JHS 49.6 - June 2024 - 757
JHS 49.6 - June 2024 - 758
JHS 49.6 - June 2024 - 759
JHS 49.6 - June 2024 - 760
JHS 49.6 - June 2024 - 761
JHS 49.6 - June 2024 - 762
JHS 49.6 - June 2024 - 763
JHS 49.6 - June 2024 - 764
JHS 49.6 - June 2024 - 765
JHS 49.6 - June 2024 - 766
JHS 49.6 - June 2024 - 767
JHS 49.6 - June 2024 - 768
JHS 49.6 - June 2024 - 769
JHS 49.6 - June 2024 - 770
JHS 49.6 - June 2024 - 771
JHS 49.6 - June 2024 - 772
JHS 49.6 - June 2024 - 773
JHS 49.6 - June 2024 - 774
JHS 49.6 - June 2024 - 775
JHS 49.6 - June 2024 - 776
JHS 49.6 - June 2024 - 777
JHS 49.6 - June 2024 - 778
JHS 49.6 - June 2024 - 779
JHS 49.6 - June 2024 - 780
JHS 49.6 - June 2024 - 781
JHS 49.6 - June 2024 - 782
JHS 49.6 - June 2024 - 783
JHS 49.6 - June 2024 - 784
JHS 49.6 - June 2024 - 785
JHS 49.6 - June 2024 - 786
JHS 49.6 - June 2024 - 787
JHS 49.6 - June 2024 - 788
JHS 49.6 - June 2024 - 789
JHS 49.6 - June 2024 - 790
JHS 49.6 - June 2024 - 791
JHS 49.6 - June 2024 - 792
JHS 49.6 - June 2024 - 793
JHS 49.6 - June 2024 - 794
JHS 49.6 - June 2024 - 795
JHS 49.6 - June 2024 - 796
JHS 49.6 - June 2024 - 797
JHS 49.6 - June 2024 - 798
JHS 49.6 - June 2024 - 799
JHS 49.6 - June 2024 - 800
JHS 49.6 - June 2024 - 801
JHS 49.6 - June 2024 - 802
JHS 49.6 - June 2024 - 803
JHS 49.6 - June 2024 - 804
JHS 49.6 - June 2024 - 805
JHS 49.6 - June 2024 - 806
JHS 49.6 - June 2024 - 807
JHS 49.6 - June 2024 - 808
JHS 49.6 - June 2024 - 809
JHS 49.6 - June 2024 - 810
JHS 49.6 - June 2024 - 811
JHS 49.6 - June 2024 - 812
JHS 49.6 - June 2024 - 813
JHS 49.6 - June 2024 - 814
JHS 49.6 - June 2024 - 815
JHS 49.6 - June 2024 - 816
JHS 49.6 - June 2024 - 817
JHS 49.6 - June 2024 - 818
JHS 49.6 - June 2024 - 819
JHS 49.6 - June 2024 - 820
JHS 49.6 - June 2024 - 821
JHS 49.6 - June 2024 - 822
JHS 49.6 - June 2024 - 823
JHS 49.6 - June 2024 - 824
JHS 49.6 - June 2024 - 825
JHS 49.6 - June 2024 - 826
JHS 49.6 - June 2024 - 827
JHS 49.6 - June 2024 - 828
JHS 49.6 - June 2024 - Cover3
JHS 49.6 - June 2024 - Cover4
https://www.nxtbookmedia.com