Differential Diagnosis of Neurogenic Thoracic Outlet Syndrome (NTOS)

Tenderness is supraclavicular fossa, numbness patterns, tinel’s sign either supraclavicular, axillary or elbow cubital areas all point to NTOS. Triggers in trapezuis, rhomboids and levator scap are common in NTOS as well.

Differential Diagnosis in Patients with Possible NTOS
Sheldon E. Jordan
Thoracic Outlet Syndrome  2013, pp 49-60

Differential diagnosis would include:

  • Cervical radiculitis – more neck movement restriction; spurling conpression positive sometime; numbness 4th and fifth fingers uncommon as “disc herniation and osteophytic spurs do not commonly occur at the C8 root level”. Supraclavicular pains less pronounced.
  • Neck facets -cervical pain radiating  to scapula; genderness to neck facets though blocks to there often needed for confirmation (dangerous and no one will do that here – facet syndromes in neck do not exit as such in this region…. Facets syndromes can co-exist with NTOS
  • Dystonia – may see elevated shoulder on one side; torticollis
  • Myofascial pains – knots
  • Rotator cuff and labral lesions shoulder – unfortunately 28/110 cases of shoulder issues were found to have co-existing NTOS after the shoulder was successfully treated with surgery,
  • Carpal tunnel syndrome (CTS )- “Both CTS and NTOS patients may have a history of worsening pain and paresthesias at night and with repetitive hand activities and with arm elevation”                                      – numb hand or inner fingers in CTS while NTOS is  either whole hand or outer fingers.
    – Tinel’s wrist for carpal tunnel versus tinels supraclavicular, in axilla or in ulnar cubital area for NTOS; supraclavicular pains in NTOS
    – CTS thenar atophy/weakness; NTOS hypothenar weakness
  • ulnar neuropathy – numb outer 2 fingers and pain cubital area elbow – trouble holding paper between two fingers
  • Complex Regional Pain syndrome – 17% of DD NTOS – an impossible to treat “game player”
  • Fibromyalgia –  widespread issues – 7 cases of NTOS with fibromyalgia all did poorly with surgery
  • cervicobrachial occupational injuries of “somatization” nature – so few cases of NTOS took any advantage of any entitlement programs that author felt this was rare.
  • Opioid hyperalgesia – “worsened regional pain and overall pain sensitization associated with chronic exposure to high daily doses of opioids” – Talked to Dr. Harold Mersky, one of the psychiatric fathers of pain clinical research, about this condition – he has not particularly seen it. Several posters at the 2011 IASP congress in Montreal looked for it unsuccessfully.  Doesn’t sound they were successful at doing anything for it and foretold bad things to all their cases with it. Would have been interested to see what temporary relief could be achieved from an interscalene block – were they missing some CRPS cases?

Comment – My problem has been how much does it exist as a comorbidity with other conditions.  I too, have a case where the shoulder issue was taken care of by surgery but the TOS (has vascular component too) persisted.  Cases of fibromylgia with NTOS are a very bad combination.  Lots of cases of subclinical radiculopathy with NTOS complicating things.

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